Long-term sedative use among community-dwelling adults: a population-based analysis

Trends and patterns of benzodiazepines and Z-drugs prescriptions in Australian general practice: A national study (2011-2018)

INTRODUCTION

We aimed to explore trends and sociodemographic patterns in benzodiazepine (BZD) (by half-life) and Z-drugs prescribing in Australian general practice.

METHODS

This open cohort study used de-identified electronic health records of 1.4 million patients (50,812,413 consultations) from 402 Australian practices (MedicineInsight 2011-2018). Annual prescribing frequency and changes over time were estimated according to sex, age, socioeconomic position and rurality.

RESULTS

Between 2011 and 2018, the prescribing of very short-acting BZD increased from 0.10 to 0.29 per 1000 consultations (average annual change +17.2% [95% CI 9.6; 25.3]), while it declined for short-intermediate (from 38.5 to 26.6 per 1000 consultations; annual change -5.1% [95% CI -5.6; -4.5]), long-acting BZD (from 24.1 to 21.6 per 1000 consultation; annual change -1.5% [95% CI -2.2; -0.8]) and Z-drugs (from 4.6 to 4.0 per 1000 consultations; annual change -1.9% [95% CI -3.0; -0.7]). Short-intermediate-acting BZD prescribing was three times more frequent among women aged 65+ years than younger women, and long-acting BZD three-to-four times more likely among younger than older men. Z-drugs prescribing was higher among women aged 45-64 years than younger or older females. Short-intermediate- and long-acting BZD were more likely prescribed for patients from more disadvantaged areas, and Z-drugs in more advantaged areas. There were no disparities by rurality.

DISCUSSION AND CONCLUSIONS

Although most BZD and Z-drugs prescriptions declined over time, short-intermediate BZD prescriptions remained higher among older women and long-acting BZD more frequent among younger men, especially for those living in more disadvantaged areas. Targeted interventions could reduce the prescribing of BZD and Z-drugs in these groups.

Blended care to discontinue BZRA use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care

STUDY OBJECTIVES

International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice.

METHODS

A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally six months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles.

RESULTS

In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0·924; 95% CI: 0·60, 1·43). No adverse events were reported to the research team.

CONCLUSIONS

The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice.

Long-term benzodiazepines and z-drug prescribing in Australian general practice between 2011 and 2018: A national study

Despite reducing benzodiazepine prescribing, benzodiazepine-involving deaths have substantially increased in Australia. This study aimed to explore patterns in long-term prescribing of medications (benzodiazepine and z-drugs [BZD]) used for sleep-issues/insomnia in Australia to better understand these changes. Open cohort study using de-identified electronic health records of 1 414 593 adult patients regularly attending 404 Australian general practices from 2011 to 2018 (MedicineInsight). We used logistic regression adjusted for patient and practice characteristics to; (1) estimate long-term BZD prescribing prevalence (≥3 prescriptions in 6 months) and the associated sociodemographic factors, and (2) Poisson regression to compute annual changes in prescribing rates. Long-term BZD prescribing changed from 4.4% in 2011 to 5.8% in 2015, remaining relatively stable until 2018 (annual increase +2.5% [95% CI +2.0%;+3.0%]). Long-term BZD prescribing in any year was up to six times more likely in elderly rather than in younger patients and 30%-43% more prevalent in females, or patients living in or attending a practice located in more disadvantaged areas. The increase was more pronounced among males, adults aged 35-49 years, and individuals living in advantaged areas. The median duration among incident cases decreased from 1183 to 322 days between 2011 and 2017, and was up to 197 days longer among elderly females than males. Despite a slight increase and recent stability in long-term BZD prescribing, the higher rates and durations among elderly patients, women, or those living in more disadvantaged areas are concerning and highlights the need for interventions that reduce the potential harms of long-term BZD use in vulnerable groups.

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis

BACKGROUND

In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.

OBJECTIVE

To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.

DESIGN

Interrupted time series analysis of population-based hospitalization data.

PARTICIPANTS

Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.

MAIN MEASURES

The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.

KEY RESULTS

A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.

CONCLUSION

The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov ID, NCT03256734.

The patterns and burden of multimorbidity in geriatric patients with prolonged use of addictive medications

Background

Multimorbidity and prolonged use of addictive medications are prevalent among older patients, and known to increase the risk of adverse drug events. Yet, the relationship between these two entities has remained understudied.

Aims

This study explored the association between multimorbidity burden and prolonged use of addictive medications in geriatric patients, adjusted for clinically important covariates. Furthermore, we identified comorbidity patterns in prolonged users.

Methods

We conducted a cross-sectional study on a consecutive sample of 246 patients, aged 65–90 years, admitted to a large public university hospital in Norway. We defined prolonged use of addictive medications as using benzodiazepines, opioids and/or z-hypnotics beyond the duration recommended by clinical guidelines (≥ 4 weeks). Multimorbidity was assessed with the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), based on diagnoses made by independent physicians.

Results

Compared to non-prolonged use, prolonged use was significantly more common among patients who had psychiatric (19/27, 70%), liver (19/22, 86%), upper gastrointestinal tract (21/32, 66%), musculoskeletal (52/96, 54%), or nervous system disorders (46/92, 50%). Patients with prolonged use had a higher multimorbidity burden than those without such use (CIRS-G score, mean = 7.7, SD = 2.7 versus mean = 4.6, SD = 2.2, p < 0.001). Multivariable logistic regression indicated a significant association between multimorbidity burden and prolonged addictive medication use (OR = 1.72, 95% CI 1.42–2.08). Predictive margins postestimation showed a systematic increase in the predicted CIRS-G scores when the number of addictive drug used increases.

Conclusions

Multimorbidity is strongly associated with prolonged use of addictive medications. Multiple substance use may aggravate disease burden of older patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01791-5.

Benzodiazepine deprescription strategies in chronic users: a systematic review

BACKGROUND

As long-term use of benzodiazepines increases, adverse effects also become more frequent, especially in elderly adults. Due the potential of causing dependence, poor patient adherence and a lack of awareness of side effects, deprescription is challenging.

OBJECTIVE

This study aimed to identify what are the effective approaches to motivate and promote deprescription of benzodiazepines.

METHODS

We used MeSH terms to search in five databases that were MEDLINE, Cochrane CENTRAL, LILACS, SCIELO and Science Direct. Then, we selected articles accordingly to inclusion and exclusion criteria. Risk of bias assessment for randomized controlled trials and prospective interventional studies was made using RoB 2.0 and ROBINS-I tools, respectively. For cohort studies, we used the clarity group by McMaster University tool.

RESULTS

Database search retrieved 412 results, and 11 studies were selected for analysis. Interventions focusing on patient education to improve community awareness about deprescription presented better discontinuation rates and more potential on motivating discussions about deprescribing with physicians. Interventions based on counselling by different health professionals were not well evaluated as they presented four of six studies as high, serious or critical risk of bias.

CONCLUSIONS

Although the comparison of different strategies was impaired by the high risk of bias in some studies, patient education focused interventions presented good results. Future studies should consider doing a follow-up of 6 months or longer with evaluation of withdrawal symptoms and sleep patterns, inclusion of young adults on the sample and some form of cognitive evaluation that might influence the results of the intervention.

Addressing Barriers to Reducing Prescribing and Implementing Deprescribing of Sedative-Hypnotics in Primary Care

Objective:

To describe interventions that target patient, provider, and system barriers to sedative-hypnotic (SH) deprescribing in the community and suggest strategies for healthcare teams.

Data Sources:

Ovid MEDLINE ALL and EMBASE Classic + EMBASE (March 10, 2021).

Study Selection and Data Extraction:

English-language studies in primary care settings.

Data Synthesis:

20 studies were themed as patient-related and prescriber inertia, physician skills and awareness, and health system constraints. Patient education strategies reduced SH dose for 10% to 62% of participants, leading to discontinuation in 13% to 80% of participants. Policy interventions reduced targeted medication use by 10% to 50%.

Relevance to Patient Care and Clinical Practice:

Patient engagement and empowerment successfully convince patients to deprescribe chronic SHs. Quality improvement strategies should also consider interventions directed at prescribers, including education and training, drug utilization reviews, or computer alerts indicating a potentially inappropriate prescription by medication, age, dose, or disease. Educational interventions were effective when they facilitated patient engagement and provided information on the harms and limited evidence supporting chronic use as well as the effectiveness of alternatives. Decision support tools were less effective than prescriber education with patient engagement, although they can be readily incorporated in the workflow through prescribing software.

Conclusions:

Several strategies with demonstrated efficacy in reducing SH use in community practice were identified. Education regarding SH risks, how to taper, and potential alternatives are essential details to provide to clinicians, patients, and families. The strategies presented can guide community healthcare teams toward reducing the community burden of SH use.

The Smarter Sleep educational interventions: an initiative to reduce hypnotic prescribing in in-patient psychiatric care

AIMS AND METHOD

In-patients on mental health wards are commonly prescribed hypnotics for the long-term management of disturbed sleep. Specific sleep disorders remain underdiagnosed and effective behavioural interventions are underused. We developed a suite of three educational interventions (a video, poster and handbook) about sleep, sleep disorders, the safe prescribing of hypnotics and use of psychological strategies (sleep hygiene and cognitive-behavioural therapy for insomnia, CBTi) using co-design and multiprofessional stakeholder involvement. This controlled before-and-after study evaluated the effectiveness of these interventions across seven in-patient psychiatric wards, examining their impact on hypnotic prescribing rates and staff confidence scores (data collected by retrospective drug chart analysis and survey respectively).

RESULTS

A marked reduction was seen in the percentage of patients prescribed hypnotics on in-patient prescription charts (-24%), with a 41% reduction in the number of hypnotics administered per patient (mean reduction -1.142 administrations/patient).

CLINICAL IMPLICATIONS

These simple educational strategies about the causes and treatment of insomnia can reduce hypnotic prescribing rates and increase staff confidence in both the medical and psychological management of insomnia.

Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis

AIMS

To assess the effectiveness of brief interventions in primary care aimed at reducing or discontinuing long-term benzodiazepine/Z-drug (BZRA) use.

METHOD

Systematic review of randomized controlled trials of brief interventions in primary care settings aimed at reducing or discontinuing long-term BZRA use in adults taking BZRAs for ≥ 3 months. Four electronic databases were searched: PubMed, EMBASE, PsycINFO and CENTRAL. The primary outcome was BZRA use, classified as discontinuation or reduction by ≥ 25%. The Theoretical Domains Framework (TDF) was used to retrospectively code behavioural determinants targeted by the interventions. The Behaviour Change Technique (BCT) Taxonomy was used to identify the interventions' active components. Study-specific estimates were pooled, where appropriate, to yield summary risk ratios (RRs) and 95% confidence intervals (CIs). Pearson's correlations were used to determine the relationship between intervention effect size and the results of both the TDF and BCT coding.

RESULTS

Eight studies were included (n = 2071 patients). Compared with usual care, intervention patients were more likely to have discontinued BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25). TDF domains 'knowledge', 'memory, attention and decision processes', 'environmental context and resources' and 'social influences' were identified as having been included in every intervention. Commonly identified BCTs included 'information about health consequences', 'credible source' and 'adding objects to the environment'. There was no detectable relationship between effect size and the results of either the TDF or BCT coding.

CONCLUSION

Brief interventions delivered in primary care are more effective than usual care in reducing and discontinuing long-term benzodiazepine/Z-drug use.

Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood.

OBJECTIVES

To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada.

METHODS

A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed.

RESULTS

Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001).

CONCLUSIONS

BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.

One-year persistence of potentially inappropriate medication use in older adults: A population-based study

AIMS

To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada.

METHODS

A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM.

RESULTS

In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases.

CONCLUSIONS

One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.

Use of benzodiazepines and z-drugs not compliant with guidelines and associated factors: a population-based study

Benzodiazepines and z-drugs are primarily indicated for the treatment of sleep disorders and anxiety symptoms. Their frequent long-term use contrasts with the international guidelines that limit treatment duration to a maximum of 4 weeks. The objective of this study was to assess the frequency of their use that was not in accordance with guidelines in the French general population between 2007 and 2012 and associated characteristics. A cohort of 67,550 benzodiazepine new users was set up in an exhaustive database for health-care reimbursements and representative of the French population. Benzodiazepine use not in accordance with guidelines was defined as the concomitant dispensation of several benzodiazepines, the dispensation of treatment over a period longer than recommended, or a new dispensing within the 2 months following the end of a previous treatment of maximum recommended duration, considering that French recommendations distinguish between hypnotic (4 weeks) and anxiolytic benzodiazepines (12 weeks). Benzodiazepine use not in accordance with guidelines was high, in about 30% of new hypnotic users and 20% of new anxiolytic users. Its frequency was stable over the study period. Associated characteristics were similar for new hypnotic or anxiolytic users, i.e.. older age, treatment initiation by a psychiatrist, presence of a chronic disease, hospitalization, or another psychotropic treatment. These findings provide a solid basis for establishing a public health policy to reduce benzodiazepine use not compliant with guidelines. They should be further explored in patients most at risk in the present study, e.g., patients treated by a psychiatrist.

Interventions to improve benzodiazepine tapering success in the elderly: a systematic review

BACKGROUND

Long-term benzodiazepine use in the elderly population is a significant public health problem that leads to impaired cognitive functioning, medication dependence and increased risks for adverse drug reactions. The aim of this review was to examine randomized controlled trials (RCTs) on the efficacy of different methods for tapering and discontinuing benzodiazepines.

METHOD

We used four databases (Ovid, PubMed, Academic Search Complete, Web of Science) to retrieve randomized controlled trials published in peer-reviewed journals that explored different methods for tapering benzodiazepine use in a primarily geriatric population.

RESULTS

Eleven papers met the inclusion criteria. Methods to assist in benzodiazepine tapering included patient education, cognitive behavioural therapy (CBT), and pharmaceutical adjuvants (SSRIs, melatonin, progesterone). Patient education was consistently effective in increasing benzodiazepine discontinuation success while CBT had mixed but promising results. The use of medications to help improve tapering success was inconclusive.

CONCLUSIONS

Patient education is a successful, time- and cost-effective intervention that can significantly help with benzodiazepine discontinuation success. CBT may also be an effective approach. However, cost can be an issue since public healthcare coverage in Canada does not cover psychotherapy. More research is needed in looking at pharmaceutical adjuvants and their role in assisting with benzodiazepine discontinuation.

Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle

Objective:

This study aimed to determine the prevalence of benzodiazepine (BZD) use in Brazil and to investigate the direct and indirect effects of alcohol consumption, sedentary lifestyle (SL), depressive symptoms (DS), and sleep dissatisfaction (SD) on BZD use.

Methods:

The Second Brazilian Alcohol and Drugs Survey (II BNADS) used stratified cluster probabilistic sampling to select 4,607 individuals aged 14 years and older from the Brazilian household population.

Results:

The lifetime and 12-month prevalence of BZD use was 9.8 and 6.1%, respectively. Older participants (age 40 and older) and women had higher rates. Alcohol use disorder, DS, and SD were significantly more prevalent in BZD users. The parallel multiple mediator model showed a positive direct effect of alcohol consumption on BZD use, with significant positive indirect effects of SL, SD, and DS as simultaneous mediators leading to higher BZD intake. Other statistically significant indirect pathways were DS alone, SD alone, and all of the above except SL.

Conclusion:

The prevalence of BZD use in Brazil is high compared to that of other countries. Knowledge of the main risk factors and pathways to consumption can guide prevention initiatives and underlie the development of better tailored and effective treatment strategies.

Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis

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.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015

AIMS

The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland.

METHODS

A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated.

RESULTS

Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period.

CONCLUSIONS

Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

Patterns, predictors and persistence of chronic sedative use: a population-based observational study of older adults in British Columbia, Canada

BACKGROUND

Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada.

METHODS

This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years.

RESULTS

Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013.

INTERPRETATION

Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.