Détournement d’usage du trihexyphénidyle (Artane®, Parkinane®) : tendances récentes

Systematic assessment of non-medical use of prescription drugs using doctor-shopping indicators: A nation-wide, repeated cross-sectional study

AIMS

The aim of this study was to present the first nation-wide, systematic, repeated assessment of doctor-shopping (i.e. visiting multiple physicians to be prescribed the same drug) during 10 years for more than 200 psychoactive prescription drugs in the 67 million inhabitants in France.

DESIGN

This was a nation-wide, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Data are from the French National Health Data System in 2010, 2015 and 2019 for 214 psychoactive prescription drugs (i.e. anaesthetics, analgesics, antiepileptics, anti-Parkinson drugs, psycholeptics, psychoanaleptics, other nervous system drugs and antihistamines for systemic use).

MEASUREMENTS

The detection and quantification of doctor-shopping relied upon an algorithm that detects overlapping prescriptions from repeated visits to different physicians. We used two doctor-shopping indicators aggregated at population level for each drug dispensed to more than 5000 patients: (i) the quantity doctor-shopped, expressed in defined daily doses (DDD), which measures the total quantity doctor-shopped by the study population for a given drug; and (ii) the proportion doctor-shopped, expressed as a percentage, which standardizes the quantity doctor-shopped according to the use level of the drug.

FINDINGS

The analyses included approximately 200 million dispensings to approximately 30 million patients each year. Opioids (e.g. buprenorphine, methadone, morphine, oxycodone and fentanyl), benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) (e.g. diazepam, oxazepam, zolpidem and clonazepam) had the highest proportions doctor-shopped during the study period. In most cases, the proportion and the quantity doctor-shopped increased for opioids and decreased for benzodiazepines and Z-drugs. Pregabalin had the sharpest increase in the proportion doctor-shopped (from 0.28 to 1.40%), in parallel with a sharp increase in the quantity doctor-shopped (+843%, from 0.7 to 6.6 DDD/100 000 inhabitants/day). Oxycodone had the sharpest increase in the quantity doctor-shopped (+1000%, from 0.1 to 1.1 DDD/100 000 inhabitants/day), in parallel with a sharp increase in the proportion doctor-shopped (from 0.71 to 1.41%). Detailed results for all drugs during the study period can be explored interactively at: https://soeiro.gitlab.io/megadose/.

CONCLUSIONS

In France, doctor-shopping occurs for many drugs from many pharmacological classes, and mainly involves opioid maintenance drugs, some opioids analgesics, some benzodiazepines and Z-drugs and pregabalin.

[Increasing methylphenidate abuse: Tracking and profiles during 13-years]

BACKGROUND

Methylphenidate is indicated for attention deficit hyperactivity disorder (ADHD). Several studies have evaluated its abuse in specific populations (students, drug users) and few in the general population. This work describes the extent of its abuse in a region of more than 5 million inhabitants.

METHOD

Based on regional health insurance data from 2005 to 2017, the clustering method identifies different methylphenidate use profiles according to several characteristics (number of different prescribers and pharmacies, number of dispensations, number of defined daily dose dispensed). The groups characterised by high values of these variables will be qualified as "deviant".

RESULTS

In 13 years, the number of patients with at least one dispensation in the first quarter has been multiplied by 5.8 times. The proportion of adults has increased (20% in 2017) and their number has been multiplied by 10. Five groups are identified, three of them are characterised by "deviant" behaviour. Group 5 (n=11, 0.04%) has higher values than 4 (n=112, 0.4%) and 3 (n=407, 1.6%). These patients are older and more frequently use benzodiazepines and opiate substitution drugs. Groups 1 (n=13,132, 51%) and 2 (n=11,941, 46.7%) are more likely to be taken up by young subjects. The number of subjects with "deviant" behaviour increased until 2011 and after a decrease, the highest number of subjects concerned has been observed since 2015.

CONCLUSION

In view of the increase of subjects with "deviant" behaviour, it is necessary to make the medical community and patients aware on the risk of abuse of methylphenidate. The recent extension of the indication for ADHD in adults and the broadening of the conditions of prescription require increased vigilance.

[Reimbursement of opiate substitution drugs to militaries in 2007]

INTRODUCTION

The use of psychoactive drugs by militaries is not compatible with the analytical skills and self-control required by their jobs. Military physicians take this problem into consideration by organising systematic drugs screening in the French forces. However, for technical reasons, opiates are not concerned by this screening with the agreement of the people concerned. The estimated number of militaries who use an opiate substitute may be an approach of heroin consumption in the French forces. This study describes buprenorphine and methadone reimbursements made during 2007 by the national military healthcare centre to French militaries.

MATERIAL AND METHOD

Each French soldier is affiliated to a special health insurance. The national military healthcare centre has in its information system, all the data concerning drug reimbursement made to French military personnel. This is a retrospective study of buprenorphine and methadone reimbursements made during 2007 by the military healthcare centre, to militaries from the three sectors of the French forces, and from the gendarmerie and joint forces. Only one reimbursement of one of these two drugs during this period allowed the patient to be included in our study. Daily drug dose and treatment steadiness profile have been calculated according to the criteria of the French monitoring centre for drugs and drug addiction. The criteria of the National guidelines against frauds have been used to identify misuse of these drugs. Doctors' shopping behaviour has also been studied. Finally, the nature of the prescriber and the consumption of other drugs in combination with opiate substitute have been analysed.

RESULTS

One hundred and eighty-one military consumers of opiate substitute drugs (167 men and 14 women) participated. This sample included people from the three sectors of the French forces as well as from the gendarmerie and from the joint forces. The average age of the consumers was 26.6 years (20-42 years). The average length of service was 6.1 years (maximum 22 years service). One hundred and fifty-nine militaries had been delivered buprenorphine, 15 had been delivered methadone and seven had been delivered both. The prevalence of opiate substitute drug consumption by the militaries (52 per 100,000) is lower than in general population. According to the criteria of the National Healthcare Insurance, this population is not affected by abuse or fraud behaviour. Doctors' shopping behaviour is unusual. Opiate substitutes are prescribed by general physicians in 88% of issues. Only one prescriber was a military physician. An analysis of reimbursement of some drugs associated with opiate substitute has been made. The sampled military consume more psychoactive drugs (anxiolytics, antidepressants, hypnotics) than the French population under opiate substitution.

CONCLUSION

In our observation, the military physician is almost always excluded the process of substitution. His/her different responsibilities of care, but also in determining the working aptitude, lead to dissimulation behaviour by the militaries. The difficulty for military physicians is to identify such consumption. They have to evaluate the capacity to work through a physical and psychological examination.

Misuse of medicines in the European Union: a systematic review of the literature

BACKGROUND

Although awareness of the misuse of medicines is increasing, data on the extent of the problem in the European Union (EU) are lacking.

METHODS

In order to assess the magnitude and severity of the problem, a systematic review of the literature on the misuse of analgesics, opioid substitution medicines and sedatives/hypnotics (with the exception of benzodiazepines) was conducted using the PubMed and Web of Science databases. Relevant literature was identified between 2001 and 2011.

RESULTS

The main groups of misused medicines include opioid analgesics, methadone, buprenorphine and Z-drugs. Regional trends in medicine misuse indicate heterogeneity across the EU with respect to misused medicine types and research activities. Prevalence, high-risk populations and factors contributing to medicine misuse are discussed.

CONCLUSION

The implications of these findings for prevention, treatment, and policy in the EU are considered.

[Post-marketing surveillance systems for psychoactive prescription drug abuse]

Drugs affecting the central nervous system form a unique group of products for surveillance because they could be misused, abused or diverted. Considering the characteristics of this behaviour that is often concealed, specific post-marketing surveillance systems have been developed to monitor abuse of prescription drugs in some countries. The purpose of this review is to list and to describe post-marketing surveillance systems, according their methodology, in France and in foreign countries. These programs are based on adverse effect notifications, medical or legal consequences of abuse, general or specific population-based survey, professional networks or medication databases. Some programs use simultaneously several information sources. In conclusion, the multifaceted nature, the diversity and the inventiveness of post-marketing surveillance systems reflects the complexity of the abuse issue.

Patterns of methylphenidate use and assessment of its abuse and diversion in two French administrative areas using a proxy of deviant behaviour determined from a reimbursement database: main trends from 2005 to 2008

BACKGROUND

Methylphenidate is a psychostimulant drug indicated for the treatment of attention-deficit hyperactivity disorder (ADHD). Its abuse and diversion have been previously described in specific populations, such as students; however, few studies investigating abuse and diversion among the overall population are available.

OBJECTIVES

The aim of this study was to describe patterns of methylphenidate use and to explore the magnitude of its abuse and diversion in two French administrative areas using data from a reimbursement database. A proxy of 'deviant behaviour' was used for the abuse and diversion of methylphenidate, defined using the following parameters: total number of defined daily doses (DDDs) of methylphenidate dispensed; number of different pharmacies seen for dispensing of methylphenidate; number of prescribers consulted for a prescription of methylphenidate; and number of dispensings of methylphenidate. Data from the reimbursement database were analysed by clustering methods. These data were assessed from 2005 to 2008.

METHOD

The French General Health Insurance System (GHIS) database was used to obtain data on methylphenidate use in two French administrative areas. Individuals affiliated to the GHIS who had a prescription for methylphenidate reimbursed between 1 January and 31 March of 4 selected years (2005, 2006, 2007 and 2008) were included. After the first dispensing of methylphenidate for these individuals, all their dispensings (including methylphenidate and other psychoactive drugs) were monitored over a 9-month period. Following a descriptive analysis, a clustering method was used to identify different subgroups of subjects according to the methylphenidate consumer profile characteristics.

RESULTS

With regard to the number of patients who had a dispensing for methylphenidate during the first quarter of the year, an 84% increase was observed between 2005 (n = 640) and 2008 (n = 1175). The clustering method identified two subgroups. One of them was characterized by a higher number of dispensings, different prescribers and pharmacies and a greater total dispensed quantity, suggesting a deviant behaviour and, thus, possible abuse and diversion of methylphenidate. These subjects were older (aged 35.4 ± 11.3 years) and were more frequently patients receiving benzodiazepines, antidepressants, antipsychotics and maintenance opioid treatment. The proportion of subjects with a deviant behaviour increased from 0.5% in 2005 to 2% in 2007 and then decreased to 1.2% in 2008.

CONCLUSION

This method was able to assess the magnitude of methylphenidate abuse liability and to follow its evolution. The decrease in methylphenidate abuse and diversion seen between 2007 and 2008 can be explained by the enactment in April 2008 of specific regulations for prescription drugs (such as methylphenidate) that are deemed by the French government to have the potential for misuse; these regulations require the establishment of a 'contract of care' between the GHIS, prescriber and patient.

Which indicators can public health authorities use to monitor prescription drug abuse and evaluate the impact of regulatory measures? Controlling High Dosage Buprenorphine abuse

BACKGROUND

Two methods have been recently developed from a drug reimbursement database to provide useful indicators for public health authorities concerning the abuse potential of psychotropic drugs. The doctor-shopping indicator (DSI) measures the proportion of the drug obtained by doctor shopping among the overall quantity of the drug reimbursed and the clustering method reveals subgroups of deviant patients.

OBJECTIVE

The objective of the study was to analyze and compare indicators resulting from these two methods, applied to High Dosage Buprenorphine (HDB) (a product well-known to be diverted in France), in order to determine which public health authorities needs they answer.

DATA ANALYSIS

The patients with reimbursed HDB were grouped using the clustering method in terms of drug dispensations characteristics over a nine month period. The characteristics of the resulting subgroups, including their DSI, were then compared.

RESULTS

4787 Patients (73.4%) had no measurable doctor-shopping behaviour. But the comparison of the two methods demonstrated that the more a patient's profile was characterized by deviant behavior, the higher was the DSI: from 0.4% in a subgroup with a median profile to 72% in a subgroup with a deviant profile.

CONCLUSION

These two methods are useful surveillance tools for public health authorities: the clustering method may help devise pertinent intervention strategies to reduce prescription drug abuse while the DSI method provides quantitative information demonstrating whether these strategies are useful. We discuss the advantages and disadvantages of using these two methods as useful indicators for public health authorities.

Evidence of clonazepam abuse liability: results of the tools developed by the French Centers for Evaluation and Information on Pharmacodependence (CEIP) network

Recent observations suggest the existence of clonazepam abuse. To determine its importance in France, a quantitative and systematic synthesis of all clonazepam data of several epidemiological tools of the Centers for Evaluation and Information on Pharmacodependence (CEIP) network has been performed in comparison with data on others benzodiazepines (BZD). Data on clonazepam and other BZD have been analysed from different epidemiological tools: OSIAP survey that identifies drugs obtained by means of falsified prescriptions, Observation of Illegal Drugs and Misuse of Psychotropic Medications (OPPIDUM) survey that describes modalities of use and data from regional French health reimbursement system. In OSIAP survey, the proportion of clonazepam falsified prescriptions among all BZD falsified prescriptions increased. During the 2006 OPPIDUM survey, the analysis of the BZD modalities of use highlights clonazepam abuse liability (for example 23% of illegal acquisition), in second rank after flunitrazepam. Studies based on data from the French health reimbursed system show that 1.5% of subjects with clonazepam dispensing had a deviant behaviour. Among BZD, clonazepam has the second most important doctor-shopping indicator (3%) after flunitrazepam. All these data provide some arguments in favour of clonazepam abuse liability in real life and the necessity to reinforce its monitoring.

Pharmacoepidemiological research using French reimbursement databases: yes we can!

PURPOSE

To describe the reimbursement databases available in France for pharmacoepidemiological research and their use.

METHODS

France has a publicly funded health system that systematically covers the population. Within this system, three main insurance schemes provide health services to citizens in France and each have their own reimbursement database. Together these three databases cover almost 97% of the French population (respectively for 54.5, 3.6, and 3.3 million individuals, and a total of 61.4 million individuals). Data in these concern patients, prescribers, all the medical acts reimbursed, prescription and undertaking of laboratory tests (but without results), private hospital data, partial public hospital data and vital status. Their use is regulated but access is free and the data are anonymous. PubMed and Scopus were searched for relevant studies published from January 1988 to June 2009.

RESULTS

110 published studies were included. The topics and the study characteristics were extremely wide-ranging. The studies assessed patterns of drug use, have tested interventions, supported or improved prescribing practices, tested compliance with the French governmental Health guidelines, assessed physicians' prescribing practices and performed economic and cost-effectiveness assessments. The number of articles published increased greatly between 2002 and 2003.

CONCLUSIONS

The French reimbursement databases were greatly used over the last 20 years. They can provide data on exposure to drugs and can be used to study patterns of drug utilization although their limitations must be considered.

Estimation of clonazepam abuse liability: a new method using a reimbursed drug database

Some observations suggest the existence of clonazepam abuse. The aim of this study was to assess its magnitude in real life by a new method, using a prescription database, and to assess its evolution between 2001 and 2006. Individuals from a region affiliated to the French health reimbursement system, who had a prescription of clonazepam reimbursed between 1 January and 15 February of two selected years were included. Their deliveries were monitored over a 9-month period. After a descriptive analysis, a clustering method illustrated by a factorial analysis was used to identify different subgroups of clonazepam consumers. An increase of 82% in participants who had a delivery of clonazepam between 2001 and 2006 was observed. Using the clustering method, this study identified some deviant participants. This group comprises a higher proportion of males, benzodiazepine users, and buprenorphine users. The number of deliveries by different prescribers and pharmacies are higher. The proportion of deviant participants increased between 2001 and 2006 (from 0.86 to 1.38%). Our method can be used to assess the magnitude of abuse liability of clonazepam and is also interesting for following its evolution, two important keys for assessing patterns of abuse.

[Creating and validating a tool able to detect fraud by prescription falsification from health insurance administration databases]

GOAL

Make it possible to spot falsified prescriptions which were delivered and reimbursed.

METHOD

1- Use health insurance administration data bases to single patients liable to suspicion of fraud (repeated presentations of the same prescription to several pharmacies the same day) 2- Attribution of a diagnosis of fraud, by the CEIP (Center of Evaluation and Information about Pharmacodependence) based on transferred data, and by the medical department analysis of the complete file, and convocation when applicable 3- Calculation of quantitative performance of the tool.

RESULTS

We have singled 2030 patients. Among them 25 were able to get 553 deliveries out of 288 pharmacies from 114 prescriptions in one year. Our tool specificity is 99.5% and its sensitivity 69.4%.

CONCLUSION

Creating this tool which can become automatic and used on a large scale, brings a new light in the evaluation, by making hindsight fraud detection possible.

Benzhexol-dependence resulting from self-medication for intermittent explosive disorder

Objective. Recent observations in Iraq during the period of sanction suggest the existence of benzhexol prescribing linked to its calming effects on explosive behaviours. This inspired our group to research the existence of this practice and the characteristics of those involved in it. Method. All patients from the psychiatric service in Merjan Hospital, Al Hilla City, Babylon Governate, Iraq, who had a prescription for benzhexol between January 1991 and December 2000, were identified. All participants received their diagnosis based on the clinical criteria of the DSM-IV, after taking a comprehensive medical and psychiatric history, mental state examination and collateral information from family members. The patients were evaluated by the same qualified consultant psychiatrist at the initial assessment and all through the period of follow-up. Results. In the 10-year period under study, 354 patients were prescribed benzhexol. A total of 190 patients diagnosed as intermittent explosive disorder (IED) and 164 suffering from severe mental disorders or personality disorders were excluded from the study. The average age of the IED group was 29.5 years. On direct questioning, the main reason patients gave most frequently for using benzhexol was to control the aggressive outbursts (N=92, 48.4), to get high (N=49, 25.8), to relax (N=26, 13.7), to get rid of boredom (N=23, 12.1). In total, the whole group were prescribed benzhexol, at an average dose of 12.5 mg/day (range 2-20 mg/day). At the time of final assessment the mean dose of prescribed benzhexol had fallen slightly to 12 mg/day (2-20 mg/day), with 10 patients being benzhexol free. Of the 190, three patients had a diagnosis of obsessive compulsive disorders, 36 patients had a diagnosis of benzodiazepines dependence, and a further five had a diagnosis of alcohol dependency syndrome. Eighty percent felt satisfied with the effect of the drug and 95 were not motivated to stop it. Conclusions. There are a significant number of patients who are routinely prescribed benzhexol as a replacement therapy. The main original reason for starting it is to control outbursts and improves their reaction to stress situations. This growing issue raises the need for awareness, by both public and medical practitioners, of the potential adverse effects of benzhexol and its untoward consequences.

Score de gravité de la pharmacodépendance : proposition d’une grille d’évaluation des notifications des CEIP

In France, the Afssaps is the body in charge of the evaluation of pharmacodependance. In order to fulfil its mission, the Afssaps has created a network of 10 Centres for Evaluation and Information on Pharmacodependance (CEIP), coordinated by the Drugs and Psychotropics Unit. Pharmacodependence notifications issued by professionals are collected by each Centre which evaluates them: it is therefore necessary to harmonize case reporting and make it possible to homogeneously evaluate the seriousness of pharmacodependence cases. Nantes CEIP has developed and has been routinely using a tool which evaluates pharmacodependence seriousness by quantifying patient consumption behaviour: the corresponding calculation, interpretation related to 3 patients is presented in this article. The association of clinical data generated by the tool, and official data coming from CEIP's, represents a powerful combination which is now available for pharmacodependence and abuse diagnosis.

How a novel programme for increasing awareness of health professionals resulted in a 14% decrease in patients using excessive doses of psychotropic drugs in western France

INTRODUCTION

Consumption of high doses of psychotropic drugs is a public health problem in France. The Center for Evaluation and Information on Pharmacodependence and the General Health Insurance System decided that it was time to begin a regional programme on excessive consumption in a French region.

PURPOSE

The objectives of this programme were: (1) get health professionals (doctors and pharmacists) to realize that some of their patients were consuming excessive doses, and (2) achieve a decrease of excessive psychotropic drug use. In addition, in the course of the programme, we were able to gather some clinical data related to heavy consumers, and evaluate their possible addiction.

METHOD

This study is based on data related to 497,821 psychotropic drug consumers. Psychotropic drugs consumers whose consumption had exceeded twice the maximum allowance during at least 3 months in the second half of 2002 were contacted and unless the patients objected, a report on their personal circumstances was sent to their doctor(s) and pharmacist(s). We determined a quantitative method for the assessment of the results.

RESULTS

Increasing awareness among the health professionals through this original programme resulted in a 14.1% decrease in the percentage of patients receiving excessive doses, a 66% decrease in the number of patients receiving more than twice the maximum recommended dose, among the selected cohort, and some rationalization of consumption as well as a decrease in the "doctor shopping" behaviour.

CONCLUSIONS

Medical practices did evolve and health professionals became aware of the benefit of their preventive action on the decrease of drug addiction.

Détournement d’usage du clonazépam (Rivotril®) : tendances récentes

Recent observations suggest the existence of clonazepam abuse. In order to determine the importance of this practice and the characteristics of these consumers, a study has been carried out, based on data from the Provence-Alpes-Côte-d'Azur and Corsica health reimbursement system. Individuals from these regions affiliated to the French health reimbursement system, who have had a prescription of clonazepam reimbursed between January 1, 2001 and February 15, 2001, have been selected. The deliveries have been monitored over a 9 month-period. 9381 subjects have been selected. A sub-group of 1.5 per cent subjects with a deviant behaviour has been identified by factorial analysis and has been compared to the sub-group without deviant behaviour. The subjects with deviant behaviour are younger and mostly male. The dosage of clonazepam is higher (10.8 mg per day versus 2.1 mg per day) with a significantly higher proportion of benzodiazepine and high-dose buprenorphine. The number of deliveries is higher (19.4 versus 5.9) as well as the number of different physicians (4.5 versus 1.5) and pharmacies (5.9 versus 1.3). This study provides some arguments in favor of the potential of abuse and dependence of clonazepam and the necessity to reinforce its monitoring. This information requires to be relayed to health professionals.

[Use of the health insurance database by the centres for evaluation and information on pharmacodependance: examples, interests and future prospects]

In France, the observation and evaluation of drug abuse and dependence associated with pychoactive medications are the responsibility of the National Commission for Narcotics and Psychotropic Drugs. In order to assist this commission, several centres for evaluation and information on pharmacodependence (CEIP) were created throughout in France. Recently, in order to complete their epidemiological tools, several centres have developed another pharmacoepidemiological approach using data for refunded prescriptions obtained from the local and regional French Health Insurance database. This article underlines the potential contribution of the Health Insurance database to improving knowledge of drug use in the real-life conditions based on studies performed by the CEIP. Several examples are given showing the extent of the possibilities (population-based studies, cohort studies, development of misuse indicators). In spite of their limitations (e.g. the difference between consumption and delivery), these examples confirm that these database may be a novel tool for CEIP to assess a potential abuse of a medication.