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Antoniou T, McCormack D, Kitchen S, Pajer K, Gardner W, Lunsky Y, Penner M, Tadrous M, Mamdani M, Juurlink DN, Gomes T. Impact of a publicly-funded pharmacare program policy on benzodiazepine dispensing among children and youth: a population-based natural experiment. BMC Pediatr 2023; 23:519. [PMID: 37858122 PMCID: PMC10585894 DOI: 10.1186/s12887-023-04331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND In January 2018, the Government of Ontario, Canada, initiated a universal pharmacare program (OHIP+) for all individuals aged 24 years and younger. In April 2019, the program was amended to cover only children and youth without private insurance. Because benzodiazepines are commonly prescribed to children and youth despite their potential hazards, we examined whether changes in publicly-funded drug coverage influenced benzodiazepine dispensing trends in this demographic. METHODS We conducted a population-based natural experiment study of benzodiazepine dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the impact of OHIP + and its subsequent modification on these trends. RESULTS The implementation of OHIP + was associated with an immediate increase in the monthly rate of benzodiazepine dispensing of 12.9 individuals per 100,000 population (95% confidence interval [CI]; 7.5 to 18.3 per 100,000). Benzodiazepine dispensing rates rose from 214.2 to 241.5 per 100,000 from December 2017 to March 2019, a 12.8% (95% CI 9.6-16.0%) increase. In stratified analyses, increases were most pronounced among females, children and youth living in the lowest income neighbourhoods and individuals aged 20 to 24. The April 2019 modification to OHIP + was not associated with changes in monthly benzodiazepine dispensing trends (0.39 individuals per 100,000; 95% CI -1.3 to 2.1 per 100,000). However, rates remained elevated relative to the period preceding OHIP + implementation. CONCLUSIONS Implementation of a publicly-funded pharmacare program resulted in more children and youth being prescribed benzodiazepines.
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Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada.
| | | | | | - Kathleen Pajer
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - William Gardner
- ICES, Toronto, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Yona Lunsky
- ICES, Toronto, ON, Canada
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Melanie Penner
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto Ontario, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Unity Health, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (Mamdani), University of Toronto, Toronto, ON, Canada
| | - David N Juurlink
- ICES, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (Mamdani), University of Toronto, Toronto, ON, Canada
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Dallman J, Aldag L, Klass A, Hadley M, Clary S, Tarakemeh A, Zackula R, Morey T, Vopat B. A Scoping Review to Assess Risk of Fracture Associated with Anxiolytic Medications. Kans J Med 2023; 16:222-227. [PMID: 37791022 PMCID: PMC10544884 DOI: 10.17161/kjm.vol16.20091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/18/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Recent research has focused on evaluating the impact of pharmalogical sources on fracture risk. The purpose of this study was to review the literature on anxiolytic medications that may be associated with an increased risk of fracture. Methods A search was conducted in MEDLINE and Embase databases to identify primary clinical studies of patients who sustained a fracture while prescribed anxiolytic medications and were published prior to July 2021. Anxiolytics defined by ATC Class N05B, beta blockers, and zolpidem were included. The search terms consisted of variations of the following: ("Psychotropic Drugs" or MeSH terms) AND ("Fracture" or MeSH terms). Results Of 3,213 studies, 13 (0.4%) met inclusion criteria and were evaluated. Fractures associated with benzodiazepine were reported in 12 of 13 studies; the highest risk occurred in patients aged 60 years and older (RR=2.29, 95% CI (1.48-4.40)). The ATC Class N05B showed an increased fracture risk for those ≤ 55 years of age that differed by sex: for men (RR=5.42, 95% CI(4.86-6.05)) and for women (RR=3.33, 95% CI (3.03-3.66)). Zolpidem also showed an increase fracture risk (RR=2.29, 95% CI(1.48-3.56)), but only during the first four weeks of treatment. A relative risk of 0.77, 95% CI(0.72-0.83) was observed for beta blockers. Conclusions Fractures are a mainstay of traumatic injuries and are accompanied by economical, physiological, and psychological hardship. With proper assessment and prophylactic measures, fracture risk can be reduced dramatically. Anxiolytic medications have been described widely to increase fracture risk, such as benzodiazepines in 60+ year old patients, and ATC Class N05B anxiolytics increased fracture risk in 55+ year old men and in 55+ year old women. Yet, some studies showed that at low doses, nitrazepam lowered fracture risk. Other anxiolytic medications, such as zolpidem and beta blockers, also showed a decrease in fracture risk. Ultimately, this scoping review helped to illuminate the inconsistency of anxiolytic fracture risk assessment while simultaneously illustrating the necessary steps to guide future research.
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Affiliation(s)
| | - Levi Aldag
- University of Kansas Medical Center, Kansas City, KS
| | - Amanda Klass
- University of Kansas Medical Center, Kansas City, KS
- Department of Psychiatry and Behavioral Sciences
| | - Morgan Hadley
- University of Kansas Medical Center, Kansas City, KS
- Department of Orthopedic Surgery and Sports Medicine
| | - Steven Clary
- University of Kansas Medical Center, Kansas City, KS
- Department of Orthopedic Surgery and Sports Medicine
| | | | - Rosey Zackula
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Office of Research
| | - Tucker Morey
- University of Kansas Medical Center, Kansas City, KS
| | - Bryan Vopat
- University of Kansas Medical Center, Kansas City, KS
- Department of Orthopedic Surgery and Sports Medicine
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Pettitt RM, Brown EA, Delashmitt JC, Pizzo MN. The Management of Anxiety and Depression in Pediatrics. Cureus 2022; 14:e30231. [DOI: 10.7759/cureus.30231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
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Dubovsky SL, Marshall D. Benzodiazepines Remain Important Therapeutic Options in Psychiatric Practice. Psychother Psychosom 2022; 91:307-334. [PMID: 35504267 DOI: 10.1159/000524400] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/29/2022] [Indexed: 12/27/2022]
Abstract
Benzodiazepines and medications acting on benzodiazepine receptors that do not have a benzodiazepine structure (z-drugs) have been viewed by some experts and regulatory bodies as having limited benefit and significant risks. Data presented in this article support the use of these medications as treatments of choice for acute situational anxiety, chronic anxiety disorders, insomnia, alcohol withdrawal syndromes, and catatonia. They may also be useful adjuncts in the treatment of anxious depression and mania, and for medically ill patients. Tolerance develops to sedation and possibly psychomotor impairment, but not to the anxiolytic effect of benzodiazepines. Sedation can impair cognitive function in some patients, but assertions that benzodiazepines increase the risk of dementia are not supported by recent data. Contrary to popular opinion, benzodiazepines are not frequently misused or conduits to misuse of other substances in patients without substance use disorders who are prescribed these medications for appropriate indications; most benzodiazepine misuse involves medications that are obtained from other people. Benzodiazepines are usually not lethal in overdose except when ingested with other substances, especially alcohol and opioids. Benzodiazepines comprise one of the few classes of psychotropic medication the mechanisms of action of which are clearly delineated, allowing for greater precision in their clinical use. These medications, therefore, belong in the therapeutic armamentarium of the knowledgeable clinician.
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Affiliation(s)
- Steven L Dubovsky
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Departments of Psychiatry and Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Dori Marshall
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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Lester TR, Bannett Y, Gardner RM, Feldman HM, Huffman LC. Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study. Front Pediatr 2022; 10:794722. [PMID: 35372169 PMCID: PMC8970594 DOI: 10.3389/fped.2022.794722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network. STUDY DESIGN/METHODS We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample. RESULTS Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription. CONCLUSIONS In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.
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Affiliation(s)
- Talia R Lester
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Yair Bannett
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rebecca M Gardner
- Quantitative Science Unit, Department of Medicine, Stanford School of Medicine, Palo Alto, CA, United States
| | - Heidi M Feldman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lynne C Huffman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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Zandonai T, Peiró AM, Fusina F, Lugoboni F, Zamboni L. Benzodiazepines in sport, an underestimated problem: Recommendations for sports medicine physicians' practice. Front Psychiatry 2022; 13:1066330. [PMID: 36620691 PMCID: PMC9810623 DOI: 10.3389/fpsyt.2022.1066330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
In the last years, only few studies in literature have focused on the use and abuse of benzodiazepines (BZDs) in sport. Benzodiazepine-related problems include misuse, addiction, driving impairments, and morbidity and mortality related to overdose and withdrawal. Two clinical cases regarding elite endurance athletes evidenced that they had started to use BZDs to counteract insomnia, to recover faster from training sessions and to manage muscle pain. One of the important points that emerged from their stories was that their sports doctors did not recognize the drugs' addictive properties, and did not intervene to gradually reduce the dosage. Experts have previously provided recommendations for BZD therapy management in clinical practice. In this article, we would like to address sports medicine physicians specifically and provide guidelines to help them manage situations involving BZD prescription, the recognition of addiction, and intervention strategies.
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Affiliation(s)
- Thomas Zandonai
- Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernández University of Elche, Alicante, Spain.,Neuropharmacology on Pain and Functional Diversity, Institute of Health and Biomedical Research of Alicante (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, Spain.,Department of Social and Developmental Psychology, Sapienza University of Rome, Rome, Italy
| | - Ana María Peiró
- Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernández University of Elche, Alicante, Spain.,Neuropharmacology on Pain and Functional Diversity, Institute of Health and Biomedical Research of Alicante (Instituto de Investigación Sanitaria y Biomédica de Alicante), Alicante, Spain.,Pain Unit, Department of Health of Alicante, University General Hospital, Alicante, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante, University General Hospital, Alicante, Spain
| | - Francesca Fusina
- Padova Neuroscience Center, University of Padova, Padua, Italy.,Department of General Psychology, University of Padova, Padua, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy
| | - Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy
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