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Brand JA, Michelangeli M, Shry SJ, Moore ER, Bose APH, Cerveny D, Martin JM, Hellström G, McCallum ES, Holmgren A, Thoré ESJ, Fick J, Brodin T, Bertram MG. Pharmaceutical pollution influences river-to-sea migration in Atlantic salmon ( Salmo salar). Science 2025; 388:217-222. [PMID: 40208989 DOI: 10.1126/science.adp7174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 02/26/2025] [Indexed: 04/12/2025]
Abstract
Despite the growing threat of pharmaceutical pollution, we lack an understanding of whether and how such pollutants influence animal behavior in the wild. Using laboratory- and field-based experiments across multiple years in Atlantic salmon (Salmo salar; n = 730), we show that the globally detected anxiolytic pollutant clobazam accumulates in the brain of exposed fish and influences river-to-sea migration success. Clobazam exposure increased the speed with which fish passed through two hydropower dams along their migration route, resulting in more clobazam-exposed fish reaching the sea compared with controls. We argue that such effects may arise from altered shoaling behavior in fish exposed to clobazam. Drug-induced behavioral changes are expected to have wide-ranging consequences for the ecology and evolution of wild populations.
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Affiliation(s)
- Jack A Brand
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- Institute of Zoology, Zoological Society of London, London, United Kingdom
| | - Marcus Michelangeli
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- Australian Rivers Institute, Griffith University, Nathan, Queensland, Australia
| | - Samuel J Shry
- River Ecology and Management Research Group RivEM, Department of Environmental and Life Sciences, Karlstad University, Karlstad, Sweden
| | - Eleanor R Moore
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
| | - Aneesh P H Bose
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- Behavioral Evolution Research Group, Max Planck Institute of Animal Behavior, Konstanz, Germany
| | - Daniel Cerveny
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- University of South Bohemia in Ceske Budejovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Vodnany, Czech Republic
| | - Jake M Martin
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
- School of Life and Environmental Sciences, Deakin University, Waurn Ponds, Australia
- Department of Zoology, Stockholm University, Stockholm, Sweden
| | - Gustav Hellström
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
| | - Erin S McCallum
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
| | - Annika Holmgren
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
| | - Eli S J Thoré
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- Laboratory of Adaptive Biodynamics, Research Unit of Environmental and Evolutionary Biology, Institute of Life, Earth and Environment, University of Namur, Namur, Belgium
- TRANSfarm - Science, Engineering, and Technology Group, KU Leuven, Lovenjoel, Belgium
| | - Jerker Fick
- Department of Chemistry, Umeå University, Umeå, Sweden
| | - Tomas Brodin
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
| | - Michael G Bertram
- Department of Wildlife, Fish, and Environmental Studies, Swedish University of Agricultural Sciences, Umeå, Sweden
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
- Department of Zoology, Stockholm University, Stockholm, Sweden
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Swierzbiolek B, Oldenhof E, Byrne JE, Staiger PK. 'Let's talk about sleep health' within primary care: a qualitative study of patients' willingness to engage in psychological interventions for insomnia. Br J Gen Pract 2024; 74:e560-e569. [PMID: 39054078 PMCID: PMC11157562 DOI: 10.3399/bjgp.2023.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia yet remains underutilised in general practice. Understanding patient motivations and barriers to engaging in psychological interventions for insomnia is critical. Theoretical frameworks, such as the theory of planned behaviour, are needed to identify variables related to intentions and behaviour change. AIM To explore key influences that motivate individuals' intention to engage with psychological interventions for insomnia. DESIGN AND SETTING Qualitative study consisting of an online survey and interviews with 20 community-dwelling participants with insomnia aged 26-75 years residing in Victoria, Australia. METHOD Guided by the theory of planned behaviour, reflexive thematic analysis was used to identify factors influencing participants' intention to engage with psychological interventions for insomnia. RESULTS Participants reported positive attitudes towards psychological interventions for insomnia, stemming from negative beliefs about pharmacological sleep aids and the perceived benefits of a structured and evidence-based intervention. Important others positively influenced participants' intention to engage; however, the GP influence was less consistent and often indirect. Participants believed in the efficacy of psychological interventions, but several barriers hampered their ability to benefit from them. Accessibility was identified as a key facilitator, whereas lack of knowledge and clear referral pathways were the main barriers having an impact on uptake. CONCLUSION This study highlights key factors influencing patients' intention to engage in psychological interventions for insomnia as well as opportunities for GPs to support uptake and engagement. Routine conversations about sleep health are essential to reduce the burden of untreated insomnia in the community, and the active promotion of evidence-based psychological interventions is needed.
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Affiliation(s)
| | - Erin Oldenhof
- Reconnexion counsellor - Benzodiazepine Dependency Treatment Program, Reconnexion, a service of EACH; research fellow, School of Psychology, Deakin University, Burwood, Australia
| | - Jamie Em Byrne
- School of Psychology, Deakin University, Burwood, Australia
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Bushnell G, Ivanenko A, Horton DB, Lunsford-Avery JR, Posner J, Gerhard T, Suarez E, Olfson M. Psychiatric comorbidities and prescribing tendencies of sleep medications and related medications in young people with insomnia: a United States commercial claims-based analysis. Sleep 2024; 47:zsae057. [PMID: 38430553 PMCID: PMC11082474 DOI: 10.1093/sleep/zsae057] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/05/2024] [Indexed: 03/04/2024] Open
Abstract
STUDY OBJECTIVES To characterize children and youth newly diagnosed with insomnia and to describe their use of sleep and other related prescription medications. METHODS Within a commercial claims database (January 1, 2016-December 31, 2021), we identified children and youth (2-24 years) with a newly recorded insomnia diagnosis (G47.0x; F51.0x) and examined psychiatric diagnoses in the prior 6 months. We evaluated sleep and related prescription medications dispensed in the week after new insomnia diagnoses (i.e. trazodone, other antidepressants, hydroxyzine, alpha-agonists, benzodiazepines, non-benzodiazepine hypnotics "z-drugs," antipsychotics, and others). Analyses were stratified by age and psychiatric comorbidities. RESULTS Among 68 698 children and 108 118 older youth (18-24 years) with a new insomnia diagnosis, three-quarters had a diagnosed comorbid psychiatric condition; anxiety disorders, depression, and ADHD were the most common. Among those without comorbid psychiatric diagnoses, 20.2% of children and 37.4% of older youth had a sleep or related medication dispensed in the following week. In children without a comorbid psychiatric diagnosis, alpha-agonists, hydroxyzine, and trazodone were the most common medications; in older youth, trazodone was the most common medication followed by hydroxyzine, z-drugs, and SSRIs. Sleep and related prescription medications were more commonly dispensed to those with psychiatric comorbidities. From 2017 to 2021, there was an increase in hydroxyzine prescriptions following a new insomnia diagnosis and decline in z-drug and benzodiazepine prescriptions. CONCLUSIONS Our findings from a nationwide sample of young people with insomnia highlight the high prevalence of psychiatric comorbidities and variety of sleep and related medications they receive. Characterizing prescribing tendencies informs guideline development and future research.
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Affiliation(s)
- Greta Bushnell
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
| | - Anna Ivanenko
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine; Chicago, IL, USA
| | - Daniel B Horton
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School; New Brunswick, NJ, USA
| | - Jessica R Lunsford-Avery
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC, USA
| | - Jonathan Posner
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC, USA
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
- Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University; New Brunswick, NJ, USA
| | - Elizabeth Suarez
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
| | - Mark Olfson
- Department of Psychiatry, Columbia University Irving Medical Center; New York, NY, USA
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Takamine L, Krein SL, Ratliff E, Strominger J, Virk A, Maust DT. Examining Adult Patients' Success with Discontinuing Long-term Benzodiazepine Use: a Qualitative Study. J Gen Intern Med 2024; 39:247-254. [PMID: 37653209 PMCID: PMC10853089 DOI: 10.1007/s11606-023-08385-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Little is known about patients' experiences with benzodiazepine (BZD) discontinuation, which is thought to be challenging given the physiological and psychological dependence and accompanying potential for significant withdrawal symptoms. The marked decline in BZD prescribing over the past decade in the US Department of Veterans Affairs healthcare system presents an important opportunity to examine the experience of BZD discontinuation among long-term users. OBJECTIVE Examine the experience of BZD discontinuation among individuals prescribed long-term BZD treatment to identify factors that contributed to successful discontinuation. DESIGN Descriptive qualitative analysis of semi-structured interviews conducted between April and December of 2020. PARTICIPANTS A total of 21 Veterans who had been prescribed long-term BZD pharmacotherapy (i.e., > 120 days of exposure in a 12-month period) and had their BZD discontinued. APPROACH We conducted semi-structured interviews with Veteran participants to learn about their BZD use and the process of discontinuation, with interviews recorded and transcribed verbatim. Data were deductively and inductively coded and coded text entered into a matrix to identify factors that contributed to successful BZD discontinuation. KEY RESULTS The mean age of interview participants was 63.0 years (standard deviation 3.9); 94.2% were male and 76.2% were white. Of 21 participants, only 1 had resumed BZD treatment (prescribed by a non-VA clinician). Three main factors influenced success with discontinuation: (1) participants' attitudes toward BZDs (e.g., risks of long-term use, perceived lack of efficacy, potential for dependence); (2) limited withdrawal symptoms; and (3) effective alternatives, either from their clinician (e.g., medication, psychotherapy) or identified by participants. CONCLUSIONS BZD discontinuation after long-term use is relatively well tolerated, and participants appreciated reducing their medication exposure, particularly to one associated with physical dependence. These findings may help reduce both patient and clinician anxiety related to BZD discontinuation.
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Affiliation(s)
- Linda Takamine
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA.
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Erika Ratliff
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
| | - Amarra Virk
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Donovan T Maust
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Xu C, Leung JCN, Shi J, Lum DH, Lai FTT. Sedative-hypnotics and osteoporotic fractures: A systematic review of observational studies with over six million individuals. Sleep Med Rev 2024; 73:101866. [PMID: 37926010 DOI: 10.1016/j.smrv.2023.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/25/2023] [Accepted: 10/08/2023] [Indexed: 11/07/2023]
Abstract
We reviewed and meta-analyzed 20 observational studies to examine the relationship between sedative-hypnotic use and osteoporotic fractures. We searched PubMed, Embase, APA PsycINFO, and Web of Science™ for studies that used cohort, case-control, case-crossover, and self-controlled case series designs. We further assessed the quality of each study and performed meta-analyses of association estimates, e.g., odds ratios (ORs). The analysis included 6,084,083 participants and found a slight association between the use of sedative-hypnotics and osteoporotic fractures, with differing strength of associations between different classes of drugs and greater sedative-hypnotics exposure. The pooled estimates ORs for case-control studies were 1.33 (95% CI 0.98-1.80) with benzodiazepines (BZD) and any fractures, 1.32 (95% CI 1.05-1.66) with BZDs and hip fractures, and case-crossover studies were 1.15 (95% CI 0.95-1.41) with BZDs and any fractures, 1.41 (95% CI 1.08-1.85) with Z-drugs and any fractures. The study suggests that more research is needed to aid medical professionals in balancing this potential risk of osteoporotic fractures associated with sedative-hypnotic use against other reported adverse events and anticipated therapy outcomes.
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Affiliation(s)
- Chong Xu
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Janice Ching Nam Leung
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jiaying Shi
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Dawn Hei Lum
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Francisco Tsz Tsun Lai
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; Laboratory of Data Discovery for Health (D(2)4H), Hong Kong Science Park, Hong Kong Science and Technology Park, Hong Kong SAR, China.
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Liou H, Gentry MT, Leung JG, Mara KC, Staab JP, Rummans TA. Trends in Stimulant and Sedative/Hypnotic Dispensing: An Exploratory Study. J Atten Disord 2023; 27:1512-1519. [PMID: 37496458 DOI: 10.1177/10870547231187167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To investigate patterns and trends of co-prescriptions of stimulants and sedatives within the last 6 years at a tertiary care center. METHOD Patients 18 years of age and older who were dispensed at least one stimulant prescription from an institutional pharmacy between 1/1/2015 and 7/1/2021 were included. Prescription data for any co-prescribed sedative/hypnotic were collected. RESULTS Both the number of stimulant dispenses and the number of patients with stimulant dispenses increased significantly with yearly incidence rate ratios of 1.115 (95% CI [1.110, 1.119]) and 1.090 (95% CI [1.084, 1.096]), respectively. The number of patients with a stimulant dispensed who also had a benzodiazepine or "Z-drug" sedative-hypnotic dispensed at any point in the search timeframe increased significantly with incidence rate ratios of 1.077 and 1.092, respectively. The number of stimulant dispenses, number of patients with stimulant dispenses, and number of patients with a stimulant dispensed who also had both a benzodiazepine and Z-drug dispensed at any point in the search timeframe increased significantly more in Non-White than in White patients. CONCLUSIONS The results confirm previous findings of increases in dispensing of stimulants over the past 6 years and report increased polypharmacy of stimulants and sedative-hypnotics.
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Affiliation(s)
| | | | | | | | | | - Teresa A Rummans
- Mayo Clinic, Rochester, MN, USA
- Mayo Clinic, Jacksonville, FL, USA
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Ryskina K, Lo D, Zhang T, Gerlach L, Bynum J, Shireman TI. Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study. J Am Med Dir Assoc 2023; 24:1240-1246.e2. [PMID: 37088104 PMCID: PMC10524654 DOI: 10.1016/j.jamda.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/14/2023] [Accepted: 03/12/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES The use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded. METHODS Physicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics. RESULTS Of the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists. CONCLUSIONS AND IMPLICATIONS Although the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.
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Affiliation(s)
- Kira Ryskina
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Derrick Lo
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Tingting Zhang
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Lauren Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theresa I Shireman
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
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Maust DT, Bohnert ASB, Strominger J, Goldstick JE. Prescription characteristics associated with drug overdose risk among adults prescribed benzodiazepines: a cohort study. BMC Pharmacol Toxicol 2023; 24:34. [PMID: 37208726 PMCID: PMC10199543 DOI: 10.1186/s40360-023-00674-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Drug overdose (OD) deaths in the U.S. continue to rise. After opioids, benzodiazepines (BZD) are the medication most commonly involved in prescription overdoses, yet OD risk factors among those prescribed BZD are not well understood. Our objective was to examine characteristics of BZD, opioid, and other psychotropic prescriptions associated with increased drug OD risk following a BZD prescription. METHODS We completed a retrospective cohort study using a 20% sample of Medicare beneficiaries with prescription drug coverage. We identified patients with a BZD prescription ("index") claim between 1 April 2016 and 31 December 2017. In the 6 months pre-index, those without and with BZD claims comprised incident and continuing cohorts, which were split by age (incident < 65 [n = 105,737], 65 + [n = 385,951]; continuing < 65 [n = 240,358], 65 + [n = 508,230]). Exposures of interest were: average daily dose and days prescribed of the index BZD; baseline BZD medication possession ratio (MPR) for the continuing cohort; co-prescribed opioids and psychotropics. Our primary outcome was a treated drug OD event (including accidental, intentional, undetermined, or adverse effect) within 30 days of the index BZD, examined using Cox proportional hazards. RESULTS Among incident and continuing BZD cohorts, 0.78% and 0.56% experienced an OD event. Compared to 14-30 days, a < 14-day fill corresponded to higher OD risk in incident (< 65 adjusted hazard ratio [aHR] 1.16 [95% CI 1.03-1.31]; 65 + : aHR 1.21 [CI 1.13-1.30]) and continuing (< 65: aHR 1.33 [CI 1.15-1.53]; 65 + : aHR 1.43 [CI 1.30-1.57]) cohorts. Among continuing users, lower baseline exposure (i.e., MPR < 0.5) was associated with increased OD risk for those < 65 (aHR 1.20 [CI 1.06-1.36]); 65 + (aHR 1.12 [CI 1.01-1.24]). Along with opioids, concurrent antipsychotic use and antiepileptic use were associated with elevated risk of OD in all 4 cohorts (e.g., aHRs for the continuing 65 + cohort: opioid, 1.73 [CI 1.58-1.90]; antipsychotic, 1.33 [CI 1.18-1.50]; antiepileptic, 1.18 [1.08-1.30]). CONCLUSIONS In both the incident and continuing cohorts, patients dispensed fewer days' supply were at increased OD risk; those in the continuing cohort with more limited baseline BZD exposure were also at elevated risk. Concurrent medication exposures including opioids, antipsychotics, and antiepileptics were associated with short-term elevated OD risk.
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Affiliation(s)
- Donovan T Maust
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Amy S B Bohnert
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jason E Goldstick
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Kaufmann CN, Spira AP, Wickwire EM, Mojtabai R, Ancoli-Israel S, Fung CH, Malhotra A. Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018. J Clin Sleep Med 2022; 18:2459-2465. [PMID: 35818727 PMCID: PMC9516584 DOI: 10.5664/jcsm.10132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVES Recent initiatives to discourage overprescription of sleep medications have increased awareness of their potential adverse effects; however, it is unknown whether these efforts translated into a decline in use of these medications in the United States. We assessed recent national trends in the use of medications used for sleep disturbance. METHODS We used data from n = 29,400 participants in the 2013-2018 National Health and Nutrition Examination Survey. At each of three waves of in-person assessments, participants presented prescription bottles for all medications used in the prior month. Interviewers recorded each medication and participants self-reported duration and reasons for use. We identified all medications used for sleep disturbance and categorized medications into two categories: Food and Drug Administration-approved sleep medications and those used off-label for sleep disturbance. We examined changes in the prevalence in use of these medications across the study period. RESULTS The odds of using medications for sleep disturbance decreased 31% between 2013 and 2018 (odds ratio = 0.69, 95% confidence interval = 0.51-0.93, P = .015). This trend was driven by declines in use of Food and Drug Administration-approved medications for sleep disturbance, especially for medium- and long-term duration of use. Notably, among those age 80+ years, we observed an 86% decline (odds ratio = 0.14, 95% confidence interval = 0.05-0.36, P < .001) in use of Food and Drug Administration-approved sleep medications over the study period. CONCLUSIONS Use of prescription medications for sleep disturbance declined nationally, suggesting a possible effect of efforts to curb overprescription and encourage judicious use of these agents. Future research needs to examine whether these changes have coincided with improved population sleep health. CITATION Kaufmann CN, Spira AP, Wickwire EM, et al. Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018. J Clin Sleep Med. 2022;18(10):2459-2465.
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Affiliation(s)
- Christopher N. Kaufmann
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Adam P. Spira
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Center on Aging and Health, Baltimore, Maryland
| | - Emerson M. Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sonia Ancoli-Israel
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, California
| | - Constance H. Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, California
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California
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Kelley MA, Lev R, Lucas J, Knight T, Stewart E, Menchine M, Doctor JN. Association of Fatal Overdose Notification Letters With Prescription of Benzodiazepines: Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med 2022; 182:1099-1100. [PMID: 35994260 PMCID: PMC9396468 DOI: 10.1001/jamainternmed.2022.3372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/18/2022] [Indexed: 11/14/2022]
Abstract
This secondary analysis of a randomized clinical trial examines the association of receipt of an injunction letter from a medical examiner following a patient’s drug overdose with patterns of benzodiazepine prescribing among physicians.
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Affiliation(s)
- Marcella A. Kelley
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Roneet Lev
- Emergency Department, Scripps Mercy Hospital San Diego, San Diego, California
| | - Jonathan Lucas
- Department of Medical Examiner–Coroner, County of Los Angeles, California
| | - Tara Knight
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Emily Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Michael Menchine
- Department of Emergency Medicine, University of Southern California, Los Angeles
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
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11
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Burman ME, McGee N, Proctor J, Hart AM, Moody EJ, Hardesty C. ECHO: A Model for Professional Development in Nursing Through Learning Networks. J Contin Educ Nurs 2021; 52:198-204. [PMID: 34038238 DOI: 10.3928/00220124-20210315-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Health research is published at a breathtaking pace and quantity; however, even when research is systematically developed into best practices and/or clinical guidelines, it often is not implemented into practice. Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based professional development approach that can help nurses to stay current and apply new knowledge to practice. The purpose of this article is to describe ECHO as a model for professional development and capacity building through learning networks. This article describes the ECHO model, evidence supporting its use, the infrastructure needed to implement an ECHO network, and two nursing ECHO learning networks. [J Contin Educ Nurs. 2021;52(4):198-204.].
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12
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How do medical and non-medical use of z-drugs relate to psychological distress and the use of other depressant drugs? Addict Behav 2021; 112:106606. [PMID: 32818728 DOI: 10.1016/j.addbeh.2020.106606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Z-drugs are hypnotic drugs used for insomnia with considerable potential of abuse. We investigated the relationship of past-year medical and non-medical use of z-drugs with past-year: i) psychological distress; ii) medical use, non-medical use, and DSM-IV use disorder of Benzodiazepine (BZD) tranquilizers; iii) use and DSM-IV alcohol and marijuana use disorders, recreational drugs with a depressant effect on the central nervous system. METHODS Data came from the 2015-2017 NSDUH (n = 128,740). Participants aged 18+ were asked if they had used any Z-Drug medically or non-medically in the past year. We investigated the associations between the three-level z-drugs variable with psychological distress and BZD, alcohol, and marijuana variables in multinomial logistic regression models. RESULTS Past-year prevalences of z-drug use were 3.3% for medical and 0.5% for non-medical use. Medical and non-medical users of z-drugs had higher risk of psychological distress, compared to non-users. Medical and non-medical users of z-drugs had higher risk of medical use, non-medical use, and BZD use disorders. Compared to non-users of z-drugs, medical users had higher risk of marijuana and alcohol use and alcohol use disorders, while non-medical users had higher risk of marijuana use and marijuana use disorders and alcohol. CONCLUSION Z-drug users have elevated risk of use and dependence of BZDs and recreational drugs, possibly due to concurrent prescribing and self-medication.
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13
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McGee N, Proctor J, Hart AM, Burman M. Reconsidering Benzodiazepines and Z-Drug Prescriptions: Responsible Prescribing and Deprescribing. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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14
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Sweetman A, Putland S, Lack L, McEvoy RD, Adams R, Grunstein R, Stocks N, Kaambwa B, Van Ryswyk E, Gordon C, Vakulin A, Lovato N. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Med Rev 2020; 56:101404. [PMID: 33370637 DOI: 10.1016/j.smrv.2020.101404] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/26/2020] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
| | | | - Leon Lack
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Robert Adams
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; The Health Observatory, Discipline of Medicine, The Queen Elizabeth Hospital Campus, University of Adelaide, Woodville, South Australia, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Ron Grunstein
- Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics, College of Medicine and Public Health, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Emer Van Ryswyk
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Vakulin
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nicole Lovato
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
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15
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Kaufmann CN, Moore AA, Bondi MW, Murphy JD, Malhotra A, Hart LA. Association Between the Use of Non-benzodiazepine Hypnotics and Cognitive Outcomes: A Systematic Review. CURRENT SLEEP MEDICINE REPORTS 2020; 6:11-20. [PMID: 33457189 DOI: 10.1007/s40675-020-00163-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose of Review Adverse effects of sedative-hypnotic medications on cognition are concerning. Past studies have examined benzodiazepine (BZD) use and cognitive outcomes; however, few studies have examined newer non-BZD hypnotic agents (nBHs; e.g. zolpidem). This systematic review examined observational studies assessing the association between nBH use and cognitive outcomes. Recent Findings Five studies met eligibility requirements and were included in the review. Most studies did not find an association between nBH use and dementia diagnosis; however, we found no studies assessing other cognitive outcomes such as cognitive performance (e.g., word recall tasks). Characterization of nBH use mostly consisted of incident new use; one study assessed nBH dosing; none examined duration of use. Studies included were of strong quality. Summary This review found no association between nBH use and dementia diagnosis, although there is a need for more research on more cognitive outcomes and nBH use patterns.
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Affiliation(s)
- Christopher N Kaufmann
- Division of Geriatrics and Gerontology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA.,Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA.,Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA
| | - Mark W Bondi
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA.,Veterans Affairs San Diego Healthcare System, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA
| | - Laura A Hart
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
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16
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Moloney ME, Ciciurkaite G, Brown RL. The medicalization of sleeplessness: Results of U.S. office visit outcomes, 2008-2015. SSM Popul Health 2019; 8:100388. [PMID: 31193373 PMCID: PMC6526300 DOI: 10.1016/j.ssmph.2019.100388] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/30/2018] [Accepted: 03/17/2019] [Indexed: 11/24/2022] Open
Abstract
Previous analysis of U.S. physician office visits (1993–2007) indicated that the medicalization of sleeplessness was on the rise and had potentially negative implications for population health. Our study asks if the medicalization of sleeplessness at the level of patient-physician interaction has persisted over time. Using the most recent years available (2008–2015) of the National Ambulatory Medical Care Survey we calculated nationally representative estimates for four sleeplessness-related outcomes of physician office visits: sleeplessness complaint, insomnia diagnosis, and prescription of benzodiazepine and non-benzodiazepine sedative-hypnotics (NBSH). To test for the significance of the linear trajectory, we ran a series of bivariate linear models. We tested three hypotheses grounded in the medicalization framework: if the medicalization of sleeplessness at the interactional level is continuing at a rate comparable to previous analyses, sleeplessness-related outcomes will continue to increase significantly over time (Hypothesis 1); NBSH prescriptions and insomnia diagnoses will continue to outpace sleeplessness complaints (Hypothesis 2); and insomnia diagnoses and use of sedative-hypnotics will increase or remain concentrated among age groups who lack the changing sleep patterns and commonly occurring comorbidities associated with older age (Hypothesis 3). Support for these hypotheses was mixed. Unlike previous analyses wherein all sleeplessness-related outcome trends were positive and statistically significant over time, regression analyses revealed a significant negative NBSH prescription trend 2008–2015 (slope, b = −699,628, P < 0.05). No other associations were significant. Younger age groups were most likely to receive an insomnia diagnosis and NBSH prescription. These trends imply that the medicalization of sleeplessness at the level of patient-physician interaction may be on the decline. We suggest that increasingly negative portrayals of sedative-hypnotics, conservative practice recommendations, and decreased direct-to-consumer advertising for NBSH may decrease consumerism and physician compliance related to the medicalization of sleeplessness. We conclude with a discussion on non-pharmaceutical methods of reducing sleeplessness relevant to population health.
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Affiliation(s)
- Mairead Eastin Moloney
- 1515 Patterson Office Tower, Department of Sociology, University of Kentucky, Lexington, KY, 40506-0027, USA
| | | | - Robyn Lewis Brown
- 1515 Patterson Office Tower, Department of Sociology, University of Kentucky, Lexington, KY, 40506-0027, USA
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17
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Magin P, Tapley A, Dunlop AJ, Davey A, van Driel M, Holliday E, Morgan S, Henderson K, Ball J, Catzikiris N, Mulquiney K, Spike N, Kerr R, Holliday S. Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis. J Gen Intern Med 2018; 33:1676-1684. [PMID: 30039495 PMCID: PMC6153232 DOI: 10.1007/s11606-018-4577-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 05/18/2018] [Accepted: 07/02/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing. OBJECTIVE To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years. MAIN MEASURES The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015). KEY RESULTS Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]). CONCLUSIONS Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.
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Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia. .,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia.
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Drug and Alcohol Clinical Services, Hunter New England Health, Newcastle, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Mieke van Driel
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Simon Morgan
- GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Kim Henderson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Jean Ball
- Hunter Medical Research Institute, Newcastle, Australia
| | - Nigel Catzikiris
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Katie Mulquiney
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Neil Spike
- Eastern Victoria GP Training, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Rohan Kerr
- General Practice Training Tasmania, Hobart, Australia
| | - Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Drug and Alcohol Clinical Services, Hunter New England Health, Newcastle, Australia
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18
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Major Depression and Sedative-Hypnotic Use Disorder: a Review. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0218-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Rhee TG. Continuing versus New Antidepressant Use in Older Adults: US Prescribing Trends from 2006 to 2015. Eur Geriatr Med 2018; 9:551-555. [PMID: 30524610 DOI: 10.1007/s41999-018-0075-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objectives Antidepressant use has increased in older adults recently. This study examines the trends of antidepressant prescribing by prescription status (continuing vs. new prescriptions). Methods Data were collected from 2006-2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based outpatient visits. I limited the sample to adults aged 65 or older (n=10,708 unweighted). Using a repeated cross-sectional design with survey sampling techniques, prevalence rates of antidepressant prescriptions were estimated by prescription status. Stratified analyses were also performed by key variables (e.g., age, gender, and race/ethnicity). Results Continuing antidepressant prescriptions increased over time significantly (OR=1.07; 95% CI, 1.03-1.11), and no temporal trend was found in new antidepressant prescriptions. In stratified analyses, the increasing trends of continuing antidepressant prescriptions were pronounced in visits to primary care physicians (OR=1.06; 95% CI, 1.01-1.12). Conclusion Increasing antidepressant prescribing trends were found in continuing prescriptions. Continued antidepressant prescribing among older adults should be monitored for appropriate use.
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Affiliation(s)
- Taeho Greg Rhee
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA. .,Yale Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA. .,Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.
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20
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21
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Kaufmann CN, Spira AP, Depp CA, Mojtabai R. Long-Term Use of Benzodiazepines and Nonbenzodiazepine Hypnotics, 1999-2014. Psychiatr Serv 2018; 69:235-238. [PMID: 29089011 PMCID: PMC5794624 DOI: 10.1176/appi.ps.201700095] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Clinical guidelines suggest that benzodiazepines (BZDs) and non-BZD hypnotics (NBHs) be used on a short-term basis. The authors examined trends in long-term BZD and NBH use from 1999 to 2014. METHODS Data included 82,091 respondents in the 1999-2014 waves of the National Health and Nutrition Examination Survey (NHANES). NHANES recorded medications used in the past 30 days on the basis of prescription bottles, and participants reported use duration. BZD and NBH use were categorized as short, medium, and long term, and time trends in use were assessed. RESULTS BZD and NBH use increased from 1999 to 2014, driven by increases in medium- and long-term use, even after adjustment for age and race-ethnicity. In most years, only a fifth of current BZD or NBH users reported short-term use. CONCLUSIONS Long-term BZD and NBH use has grown independent of U.S. demographic shifts. Monitoring of use is needed to prevent adverse outcomes.
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Affiliation(s)
- Christopher N Kaufmann
- Dr. Kaufmann and Dr. Depp are with the Department of Psychiatry, University of California, San Diego, La Jolla, California. Dr. Spira and Dr. Mojtabai are with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Adam P Spira
- Dr. Kaufmann and Dr. Depp are with the Department of Psychiatry, University of California, San Diego, La Jolla, California. Dr. Spira and Dr. Mojtabai are with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Colin A Depp
- Dr. Kaufmann and Dr. Depp are with the Department of Psychiatry, University of California, San Diego, La Jolla, California. Dr. Spira and Dr. Mojtabai are with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Ramin Mojtabai
- Dr. Kaufmann and Dr. Depp are with the Department of Psychiatry, University of California, San Diego, La Jolla, California. Dr. Spira and Dr. Mojtabai are with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
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Abstract
Hypnotics (sleeping pills) are prescribed widely, but the economic costs of the harm they have caused have been largely unrecognized. Randomized clinical trials have observed that hypnotics increase the incidence of infections. Likewise, hypnotics increase the incidence of major depression and cause emergency admissions for overdoses and deaths. Epidemiologically, hypnotic use is associated with cancer, falls, automobile accidents, and markedly increased overall mortality. This article considers the costs to hospitals and healthcare payers of hypnotic-induced infections and other severe consequences of hypnotic use. These are a probable cause of excessive hospital admissions, prolonged lengths of stay at increased costs, and increased readmissions. Accurate information is scanty, for in-hospital hypnotic benefits and risks have scarcely been studied -- certainly not the economic costs of inpatient adverse effects. Healthcare costs of outpatient adverse effects likewise need evaluation. In one example, use of hypnotics among depressed patients was strongly associated with higher healthcare costs and more short-term disability. A best estimate is that U.S. costs of hypnotic harms to healthcare systems are on the order of $55 billion, but conceivably might be as low as $10 billion or as high as $100 billion. More research is needed to more accurately assess unnecessary and excessive hypnotics costs to providers and insurers, as well as financial and health damages to the patients themselves.
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Affiliation(s)
- Daniel F Kripke
- University of California San Diego, La Jolla, CA, 92037-2226, USA
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23
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Bushnell GA, Stürmer T, Gaynes BN, Pate V, Miller M. Simultaneous Antidepressant and Benzodiazepine New Use and Subsequent Long-term Benzodiazepine Use in Adults With Depression, United States, 2001-2014. JAMA Psychiatry 2017; 74:747-755. [PMID: 28593281 PMCID: PMC5710248 DOI: 10.1001/jamapsychiatry.2017.1273] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Greta A. Bushnell
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill
| | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill
| | - Matthew Miller
- Department of Health Science, Northeastern University Bouvé College of Health Sciences, Boston, Massachusetts
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Gerlach LB, Olfson M, Kales HC, Maust DT. Opioids and Other Central Nervous System-Active Polypharmacy in Older Adults in the United States. J Am Geriatr Soc 2017; 65:2052-2056. [PMID: 28467623 DOI: 10.1111/jgs.14930] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine patterns of and trends in contributions to central nervous system (CNS) polypharmacy, defined by the Beers Criteria as three or more CNS-active medications of each medication class, of adults aged 65 and older seen in U.S. outpatient medical practices. DESIGN National Ambulatory Medical Care Survey (2004-2013). SETTING U.S. outpatient medical care. PARTICIPANTS Visits by older adults to outpatient physicians (N = 97,910). MEASUREMENTS Visits including three or more CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. The proportion of CNS polypharmacy that each medication class contributed during 2011 to 2013 was determined, and then logistic regression was used to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. RESULTS Of recent CNS polypharmacy visits, 76.2% included an opioid, and 61.8% included a benzodiazepine; 66.0% of the polypharmacy visits with benzodiazepines included opioids, and 53.3% of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (95% confidence interval (CI) = 1.23-1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (adjusted odds ratio = 2.15, 95% CI = 1.19-3.91, P = .01), and the corresponding proportion that included benzodiazepines fell. Of the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, and that of TCAs decreased. CONCLUSION In older adults, opioid use appears to be largely driving the recent national increase in CNS polypharmacy. Although concomitant use of opioids and benzodiazepines is associated with greater mortality, they are the most common contributors to CNS polypharmacy in older adults.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York.,New York State Psychiatric Institute, New York, New York
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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