Benzodiazepine utilisation in Australia: report from a new pharmacoepidemiological database

Improving the use of benzodiazepines--is it possible? A non-systematic review of interventions tried in the last 20 years

Background

Benzodiazepines are often used on a long term basis in the elderly to treat various psychological disorders including sleep disorders, some neurological disorders and anxiety. This is despite the risk of dependence, cognitive impairment, and falls and fractures. Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide. The objective of this paper is to explore interventions aimed at improving the prescribing and use of benzodiazepines in the last 20 years.

Methods

Medline, EMBASE, PsychINFO, IPA were searched for the period 1987 to June 2007.

Results

Thirty-two articles met the study eligibility criteria (interventions solely focusing on increasing appropriate prescribing and reducing long term use of benzodiazepines) and were appraised. Insufficient data were presented in these studies for systematic data aggregation and synthesis, hence critical appraisal was used to tabulate the studies and draw empirical conclusions. Three major intervention approaches were identified; education, audit and feedback, and alerts.

Conclusions

Studies which used a multi-faceted approach had the largest and most sustained reductions in benzodiazepines use. It appears that support groups for patients, non-voluntary recruitment of GPs, and oral delivery of alerts or feedback may all improve the outcomes of interventions. The choice of outcome measures, delivery style of educational messages, and requests by GPs to stop benzodiazepines, either in a letter or face to face, showed no differences on the success rates of the intervention.

Benzodiazepine use among heroin users in Sydney: patterns of use, availability and procurement

A sample of 210 heroin users who had used benzodiazepines during the preceding 6 months were interviewed about their benzodiazepine use. Forty-one percent of the sample reported having used benzodiazepines more than once a week during the 6 months preceding interview. Forty-eight percent had injected benzodiazepines, with 17% having done so during the preceding 6 months. Eleven percent of the sample reported having experienced convulsions when attempting detoxification from benzodiazepines. The majority of subjects (86%) indicated that benzodiazepines are easy or very easy to obtain. Only a third of the sample reported obtaining benzodiazepines exclusively through a doctor in the last 6 months. Over a half of the sample indicated that they had given or sold benzodiazepines to someone during that time. Diazepam was considered by subjects to be the easiest benzodiazepine to procure. Doctors should avoid the prescription of benzodiazepines to injecting drug users, particularly the more readily injectable drug temazepam. Given the widespread use of benzodiazepines by injection, research needs to examine the harm associated with the parenteral use of these drugs.

How do different age groups use benzodiazepines and antidepressants? Analysis of an Australian administrative database, 2003-6

BACKGROUND

The use of antidepressants and benzodiazepines is increasing in Australia and worldwide, and it is thought that some of the prescribing of these classes of drugs may be inappropriate. However, the demographic characteristics of the subgroups of the population responsible for this increase remain unexplored.

OBJECTIVE

The aim of this study was to examine changes in the utilization of antidepressants and benzodiazepines between different age groups within Australia from 2003 to 2006.

METHODS

The Australian Pharmaceutical Benefits Scheme administrative database was used to obtain dispensing data for all antidepressants and publicly subsidized benzodiazepines. Changes in utilization (amounts and patterns of use of different compounds) were compared between different age groups from 2003 to 2006. The WHO Anatomic Therapeutic Chemical/Defined Daily Dose system was used.

RESULTS

Use of antidepressants increased from 2003 to 2006, and in each year increased with age, with those > or = 65 years having the greatest use. Differences were seen in the antidepressant most utilized, with the elderly using more tricyclic antidepressants than those who are younger. The utilization of benzodiazepines decreased from 2003 to 2006 in elderly individuals and those receiving social welfare benefits. Individuals aged > or = 85 years had the highest use of benzodiazepines and used more long-acting benzodiazepines compared with those aged 35-44 years.

CONCLUSION

The elderly still account for most use per capita of benzodiazepines. Some of this use may be inappropriate (e.g. use of long-acting benzodiazepines) and, hence, may represent a useful target for future educational intervention. The elderly also still account for the largest per capita use of antidepressants.

Depression and remoteness from health services in South Australia

OBJECTIVE

To determine whether the prevalence of depression, its associated quality of life, treatment and mental health literacy about depression varied according to accessibility to health services.

DESIGN

Face-to-face interviews with a random and representative sample of the South Australian population (aged >or= 15 years) were conducted between March and June 2004, with the respondents stratified using the Accessibility and Remoteness Index of Australia into categories of 'highly accessible', 'accessible', and 'moderately accessible and remote'.

RESULTS

From 4700 households selected, 3015 participants were interviewed (65.9% response rate). The prevalence of major depression and other depressions was not significantly different between each of the categories, although there was a trend for those from moderately accessible and remote areas to be less depressed overall. A significantly lower proportion of respondents from moderately accessible and remote locations reported that they had family or close friends who had suffered from symptoms consistent with depression, or that they had ever had treatment for those symptoms. However, there was no significant difference between the groups in those who had ever had or who were currently taking antidepressant medication. For those who were depressed, a significantly higher proportion from the accessible, and moderately accessible and remote regions had seen a community or district health service, social worker or other counsellor as compared with those from the highly accessible area.

CONCLUSIONS

These findings indicate that depression is no more prevalent in less accessible regions of South Australia, and that when it is present, its treatment, in terms of antidepressants, which can be considered as a proxy marker for the overall management of depression, is similar to treatment in more accessible areas.

Prevalence of psychotropic use in a South Australian population

OBJECTIVE

To determine the prevalence of psychotropic medication use in a South Australian population.

METHODS

Face-to-face interviews with a random and representative sample of the South Australian population (at least 15 years of age) living in metropolitan and rural areas between March and June 2004.

RESULTS

From 4700 households selected, 3015 participants were interviewed (65.9% response rate). Of the respondents, 10.6% were taking psychotropic medications; psychotropic drug use was higher in females (14.4%) than in males (6.8%), and increased with age. Antidepressants were the most common category of psychotropics reported by respondents (6.8%), followed by anxiolytics (1.8%), hypnotics and sedatives (1.5%) and antipsychotics (0.6%). The majority (64.8%) of those respondents who were taking a tricyclic antidepressant were on a dose of 50 mg or less. Only 0.07% of respondents were taking lithium.

CONCLUSIONS

The use of psychotropic medications was higher than recently reported studies conducted in the UK, the USA, Europe and Canada. More detailed enquiry about the indication for such use appears desirable in order to ascertain whether higher use in this Australian population is clinically appropriate.

Are we going to increase the use of antidepressants up to that of benzodiazepines?

OBJECTIVE

The present study compared recent trends in benzodiazepine and antidepressant consumption in Italy and projected their global sales in the future. We investigated whether the increasing use of antidepressants is associated with a progressive reduction in benzodiazepine use.

METHODS

Data concerning actual quantities of benzodiazepines and antidepressants dispensed in Italy from 1995 to June 2003 were obtained from IMS Health. For each agent, the number of defined daily doses (DDDs) per 1000 inhabitants per day and the annual expenditure in Euros was calculated.

RESULTS

During the 9-year period, benzodiazepine consumption remained substantially stable, accounting for 50 DDDs/1000 per day in 2003. In the same period, antidepressant consumption dramatically rose, from 9 DDDs/1000 per day in 1995 to 26 DDDs/1000 per day in 2003, an increase of nearly three times. While the use of tricyclic antidepressants declined by one-third and that of other older agents remained substantially stable, the use of selective serotonin-reuptake inhibitors and newer agents (venlafaxine, mirtazapine, reboxetine) increased by 623%. Global consumption of antidepressants was projected to increase still further, and, in 2007, the total sales of antidepressants were projected to be similar to the total sales of benzodiazepines. The value of benzodiazepine sales increased from 322 million to 565 million Euros, an increase of 43%; similarly, the value of antidepressant sales increased from 186 million to 569 million Euros, an increase of 67%.

CONCLUSIONS

In Italy, the consumption of benzodiazepines was not affected by the increased prescribing of selective serotonin-reuptake inhibitors and newer antidepressants.

Use of antipsychotic medications in Australia between July 1995 and December 2001

OBJECTIVE

To examine trends in the use of oral conventional, depot and atypical anti-psychotic medications in Australia between July 1995 and December 2001.

METHOD

For each six-month interval between July 1995 and December 2001, prescription data obtained from the Health Insurance Commission of Australia were converted into a measure of drug utilization expressed as the number of defined daily doses per thousand population per day (DDDs/1000/day).

RESULTS

Between July 1995 and December 2001, use of atypical medications increased from an estimated 0.27 to an estimated 3.83 DDDs/1000/day. Use of oral conventional medications decreased from 1.76 to 0.91 DDDs/1000/day, while use of depot medications decreased from 1.38 to 0.96 DDDs/1000/day. During the latter half of 2001, atypical medications accounted for 67.3%, oral conventional medications for 16.0%, and depot medications for 16.7% of total prescriptions for antipsychotic medications dispensed through community pharmacies in Australia. The increased use of atypical medications was accounted for largely by a dramatic increase in the use of olanzapine. Between July 2001 and December 2001, prescriptions for olanzapine accounted for 65.0% of total prescriptions for atypical antipsychotic medications.

CONCLUSIONS

The results of the present study confirm that atypical antipsychotic medications have replaced conventional medications as the first-line pharmacological treatment for psychotic illness in Australia. While this change in prescribing practice is gratifying, the overwhelming preference for the use of olanzapine among clinicians prescribing antipsychotic medication is surprising and is of some concern given the significant increases in body weight that can accompany long-term use of this medication.

Abuse liability of flunitrazepam

Flunitrazepam is among the most frequently prescribed hypnotics in many countries. Although it was never marketed in the United States, flunitrazepam, in recent years, has been smuggled into the country, and reports of abuse--including alleged use of the drug to facilitate "date rape"--have attracted a great deal of scrutiny. It has been suggested that flunitrazepam may have greater liability for abuse than other benzodiazepines; such suggestions are supported by surveys of opioid abusers, many of whom report a distinct preference for flunitrazepam over other benzodiazepines. Experimental studies of animals and normal human subjects indicate that, although flunitrazepam has high efficacy and is very potent, it is pharmacologically similar to most other benzodiazepines. Although the studies are limited in number and scope, the data show no apparent differences between flunitrazepam and other benzodiazepines in ability to produce drug-taking or drug-seeking behavior, in capacity to produce physiologic dependence, nor in the characteristics of withdrawal after administration of an antagonist or discontinuation of treatment. Similar to other benzodiazepines, flunitrazepam produces dose-dependent effects on psychomotor performance and recall. Flunitrazepam does not seem to be involved in medical emergencies more often than other benzodiazepines, and there is no indication that flunitrazepam is more toxic than other benzodiazepines when taken in overdose by drug abusers or other individuals. Survey research among typical patient populations suggests that flunitrazepam is characteristic of benzodiazepines in that it is used appropriately and conservatively, with low liability for abuse. Thus the reported preference for flunitrazepam among opioid abusers seems to be the only way in which flunitrazepam is distinguished from other benzodiazepines; it is unclear what characteristics of the drug may be responsible for this reported preference. The evidence considered in this review indicates that abuse of flunitrazepam in this special population is not associated with any distinctive threats to the health of the general public.

A community survey of insomnia in Newcastle

This study aimed to estimate the prevalence of sleeping difficulty in an urban community and the frequency with which those with sleep difficulty seek medical care and use prescribed medication for sleep. Randomly selected persons aged over 16 years were invited to participate in a telephone survey. A total of 628 individuals was approached and 535 (85 per cent) were interviewed. Older subjects, women and those not in paid employment were overrepresented in the sample. Difficulty sleeping often or always was reported by 17 per cent of men and 25 per cent of women. Of subjects with difficulty in sleeping, 31 per cent had sought medical care. There was no difference between men and women in this regard. Use of prescription medication was reported by 20 per cent of men and 29 per cent of women with sleep difficulty.

Benzodiazepine use among injecting heroin users

OBJECTIVES

To determine the extent and patterns of benzodiazepine use among heroin users, and whether preferences for different benzodiazepines exist among this group.

SUBJECTS AND METHODS

210 heroin users who were current users of benzodiazepines volunteered for the study and completed a structured questionnaire.

RESULTS

Heroin users had used a median of five different benzodiazepines, most commonly diazepam. Almost half the subjects (48%; 95% CI, 41-55) had injected benzodiazepines, 17% (95% CI, 12-22) within the preceding six months. Diazepam and temazepam were the most widely injected benzodiazepines.

CONCLUSIONS

Flunitrazepam, diazepam and temazepam should be prescribed to heroin users with caution. A less popular and rarely injected benzodiazepine, nitrazepam, may be a better option for this group.

The use of benzodiazepines among regular amphetamine users

The relationship between benzodiazepine and regular amphetamine use was examined in a sample of 301 regular amphetamine users. Benzodiazepine use was widespread, with 37% of subjects having used them in the month preceding interview, and 55% in the preceding 6 months. Injectors of amphetamines were more likely to have ever used, and to be currently using, benzodiazepines. Comparisons of benzodiazepine users with other subjects indicated that benzodiazepine users had higher levels of polydrug use and psychopathology, as well as poorer health and social functioning than non-users. The odds of benzodiazepine using injectors having injected with a borrowed used needle in the preceding month were 3.8 times of those of non-benzodiazepine-using injectors. These results are consistent with studies of other groups of illicit drug users, such as heroin users, in indicating that benzodiazepine use is associated with greater levels of risk and psycho-social dysfunction.