J. Gerry Mugford, PhD, CMH

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J. Gerry Mugford, PhD, CMH Discipline of
Psychiatry Memorial University of Newfoundland
Marcella H. Sorg, RN, PhD Margaret Chase Smith
Policy Center University of Maine Terrence
Callanan, MD, FRCP Memorial University Stevan
Gressitt, MD Northeast Occupational Exchange
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Prevalence History

• North American Prevalence 10 (Pinel 2003)
• 1954 the first BZD, Chlordiazepoxide (Librium),
  (Wikipedia, 2005)
• Following decade BZDs increasingly popular for
  anxiety and sleep problems.

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History (cont.)

• Before BZDs, anxiety and sleep problems were
  often treated with barbiturates
• BZDs soon became drug of choice for treatment
  because of rapid onset and low toxicity
  (Rosenbaum, 2005)
• BZDs proved to be
• more effective
• fewer side effects
• less likely to induce dependence than
  barbiturates (Beaumont, 1990).

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Current Beliefs

• BZDs have potential risk of dependency and abuse
• Risk is lower than other sedatives, including
  barbiturates (Rosenbaum, 2005).
• BZD abuse is not common among legitimate users
• Abuse common among those already abusing other
  drugs like cocaine, opiates or alcohol
  (Rosenbaum, 2005).
• Dependency can occur even in patients who follow
  their treatment prescription and do not use for a
  long time.
• Withdrawal may occur when the medication is
  abruptly discontinued (OBrien, 2005).

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Current Beliefs (cont.)

• In addition to abuse, dependency and withdrawal,
  drawbacks of BZDs include side effects
• Sedation
• Ataxia
• Tremor
• Nausea (Pinel, 2003)
• Amnesia
• Cognitive effects (Pollack, 2005)
• Stewart (2005) long-term BZD use affects several
  cognitive functions
• Ability to learn new material
• Visuospatial deficits
• Changes in explicit memory
• Attention/concentration difficulties

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Despite the Side Effects

• Physicians generally agree
• While there are dangers associated with BZD use,
  especially long-term use, it may be necessary in
  some cases when disorders are chronic (Uhlenhuth,
  Balter, Ban et al. (1999) as cited in Rosenbaum,
  2005).

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Factors Influencing Prescribing Habits

• Both medical and non-medical factors (Hemminki
  (1975), as cited in Cutts Tett, 2003).
• Some influences include
• Physicians age
• Gender
• Year since qualification
• Continuing medical education
• Advertising
• Patient pressure
• Whether physician practices in urban or rural
  area (Cutts Tett, 2003).

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Factors Influencing Physician BZD Prescribing

• Study of GPs in Norway(Dybward et al., 1996).
• GPs report prescribing BZDs because
• Pressure from the patient
• Patient inherited from a previous physician and
  medication was simply continued
• Some physicians indicated they follow their own
  attitudes and clinical experience when
  prescribing BZDs, rather then adhering to
  official norms or guidelines

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Norway Study cont.

• GPs in Norway who issued 6 or more BZD
  prescriptions in their last practice day reported
  being more influenced by patients demands than
  did lower-prescribing physicians (Bjorner
  Laerum, 2003)

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This Survey

• April 2005-- surveys to approx. 2640 physicians
  in Maine
• Many distributed within Maine Medical Association
  newsletter
• Others sent directly to family physicians or
  circulated at a conference
• 188 (7.1) responded
• 181 (96.3) currently prescribe BZDs

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Survey Description

• 14 questions
• 10 minutes to complete
• First eight questions basic demographic
• Next whether currently prescribe BZDs
• If Yes, asked to continue survey

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Demographics Qs 1-8

• Gender
• Age
• Yr. of graduation
• Yrs. of practice
• Population size where practice?
• Type of physician e.g. psychiatrist
• Type of practice e.g. hospital based
• How they practice? e.g. group all MDs

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Responder Demographics

• 49.5 46-55 yrs. of age
• 22.0 graduated 1975-79
• 68.6 reported at least 15-19 yrs. experience
• 23.5 community size 10,000-24,999
• Males 62.8
• Males
• Older
• More medical experience
• Finished medical school earlier

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Demographics

• Practice setting
• 78.3 Office practice
• 10.9 Hospital based
• 4.9 Public clinic
• 3.3 Combination
• 2.7 Other (e.g. research)

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Demographics

• 18.9 Practice alone
• 53.0 Practice in a group of all physicians
• 28.1 Practice as in multidisciplinary team
• Physician specialties
• 46.3 General practitioners
• 18.1 Family practitioners
• 5.3 Adult psychiatrists
• 2.7 Child psychiatrists
• 0.5 Forensic psychiatrists
• 0.5 Neurologists
• 0.5 Dentists

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Specialty cont.

• 26.1 Classified other
• Approximately 30 different specialties including
  surgeon, geriatrician, internist, urologist,
  paediatrician, occupational medicine, and resident

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Which BZDs Prescribe?

• Physicians presented with a list of 14 BZD
• Generic and brand name (ex Alprazolam (Xanax)
• Indicate all BZDs they currently prescribe
• Identify additional BZDs they currently prescribe
  that are not on the list

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Reasons for Prescribing BZDs

• Eight choices offered
• Anxiety
• Insomnia
• Depression
• Movement disorder
• Alcohol withdrawal
• Muscle relaxant
• Grief reaction
• Single-dose for phobia
• List additional reasons not on the list

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Prescribe BZDs gt 90 days?

• Never
• Extended crisis in patients life
• Serious mental health diagnosis
• Chronic insomnia
• Chronic anxiety
• Indicate additional reasons not on list

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Variables Influencing Prescribing Habits?

• Cost
• Peer group
• Side effects
• Drug interactions
• Insurance coverage
• Clinical practice guidelines
• Risk of abuse/misuse
• Manufacturers information
• Pharmaceutical rep
• Indicate any additional variables

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Clinical Guidelines

• Open-ended question asking about clinical
  practice guidelines
• List which guidelines they use
• Who provides them
• Disagreements they have with the guidelines

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Other Reasons (23.9)

• Seizures
• Vertigo/anti-vertigo
• Sedation
• Panic attacks
• Pre-procedure anxiety
• Patient is already on BZDs

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Other reasons (23.3)

• Lack of response to other medication
• Patient already established on them
• PTSD
• Palliative care

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Influence on Physician Prescribing Practices
Scale

• Rated on a scale of 1 to 7
• 1 strongly agree
• 7 strongly disagree

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Influence on Physician Prescribing Practices
Neutral Variables

• Neither agree nor disagree
• Insurance coverage
• Drug availability
• Cost
• Peer group

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No Influence

• Pharmaceutical rep
• Manufacturers information

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Positive Influence

• Clinical practice guidelines
• Drug interactions
• Side effects
• Risk of abuse/misuse (most important factor)

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Average Rank of Influence Factor
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Additional Variables Offered (by 10.5)

• Patient has previously taken
• Physicians past experience
• Lack of appropriate alternatives
• Drugs effectiveness
• Lack of response to other medication
• Advice of psychiatrists or other specialists

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Are Respondents Different?
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Psychiatrists (Child, Adult) vs. Practitioners
(GP, FD)

• GP/FD practitioners
• Prescribe a greater number of BZD types
• Were more likely to prescribe
• Lorazepam (Ativan)
• Diazepam (Valium)
• Temazepam (Restoril)

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GP/FD Practitioners vs. A/C Psychiatrists
(cont.)

• GP/FD Practitioners
• Significantly more who identified
• grief reaction
• single dose for phobias
• muscle relaxant
• insomnia

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GP,FD vs. A C psychiatrists

• GP/FD Practitioners reported greater influence
  from
• manufacturers information
• cost
• insurance coverage
• No significant difference in reasons for
  prescribing beyond 90 days
• Psychiatrists were more likely to have other
  reasons for prescribing

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All-Physician Groups vs. Multidisciplinary Teams

• No significant difference in array of BZDs
  prescribed
• No difference in reasons prescribing beyond 90
  days

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All-Physician Groups vs. Multidisciplinary Teams
(cont.)

• Respondents in all-physician groups
• More likely to report prescribing BZDs for
  movement disorders
• More likely to report insurance coverage as a
  prescribing influence

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Gender Differences

• Females report higher rate of prescribing BZDs
  for grief reaction
• Females less likely to report never prescribing
  beyond 90 days
• Females report more reasons for prescribing BZDs
• Females report being more influenced by
• side effects
• drug availability
• drug interactions

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Differences related to yrs of practice lt20 vs. gt
20yrs

• More experienced more likely to prescribe
  Triazolam (Halcion)
• Less experienced more likely to prescribe
• Lorazepam (Ativan) and Clonazepam (Klonopin)
• BZDs as a muscle relaxant
• Single-dose of BZD for phobias
• Influenced by insurance coverage
• No difference in reasons for prescribing beyond
  90 days

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Smaller lt 25,000 vs. Larger Communities

• Physicians in smaller communities prescribe
• Greater number of BZDs types
• More likely to prescribe
• Clonazepam (Klonopin)
• Alprazolam (Xanax)
• Cite more reasons for prescribing BZDs
• Are more likely to prescribe citing
• single-dose for phobias
• alcohol withdrawal
• grief reaction

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Smaller vs. Larger Communities

• No significant differences in reasons for
  prescribing beyond 90 days
• Physicians in larger communities reported a
  greater influence of side effects in
  influencing their prescribing habits

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Using Guidelines

• Open-ended guidelines they use when prescribing
• Asked who provides them
• Asked whether they had any disagreements with
  these guidelines

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Guidelines (cont.)

• 50.3 failed to respond to guidelines questions
• Those who did respond
• Some said they did not use any guidelines
• Some said they relied on their own experience and
  training
• Some reported following guidelines set out by
  their hospital or governing state

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Source of Guidelines

• American Academy of Child Adolescent Psychiatry
• American Society of Addiction Medicine
• American Dental Association
• AMDA
• Society of Critical Care Medicine
• American Psychiatric Association
• AAFP
• AAP
• American Geriatric Society
• American Academy of Hospice Palliative Medicine

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Disagreements with the Guidelines

• Disagree with absolute bans (ex absolute ban on
  BZD use for anxiety or insomnia)
• Think they are overly conservative
• Feel the guidelines ignore the individual needs
  and sensitivities of the patient
• Disagreed with claims BZD use would be
  appropriate because sometimes a patient does
  poorly on anything else.

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Others Raised Concerns

• I try to use no guidelines but my conscience and
  best medical judgement. GHS is an egregious,
  financially motivated, unethical, formulary
  driven organization that, in my opinion, has and
  continues to harm thousands of patients

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Other Findings

• Physicians seem to agree that long term use is
  necessary in some cases (Rosenbaum, 2005)
• Physicians report prescribing BZDs for periods
  longer than 90 days. Of those,
• 69.4 prescribe for chronic anxiety
• 30.6 prescribe for chronic insomnia

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Limitations

• We do not know how often physicians prescribe
  long-term BZDs, we only know for what reasons
• Further studies may consider asking physicians to
  estimate the percentage of patients who are
  taking BZDs gt 90 days and for which disorders

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Summary

• Our sample
• Both genders
• Varying ages experience
• From a range of community sizes
• Alone or as part of a team
• In a hospital, office or public clinic
• Majority general practitioners (46.3) or family
  practitioners (18.1)

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Summary

• Physicians are influenced by the risk of
  abuse/misuse
• Respondents are also influenced by
• side effects,
• drug interactions
• clinical practice guidelines
• Results are similar to those in other published
  studies (Dybward et al., 1996 Bjørner Lærum,
  2003) that sampled only general practitioners
  except our sample were less influenced by
  patient pressure or that inherited patients were
  already on BZDs

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Summary (2)

• Clinical practice guidelines were reported at
  least somewhat influential by many respondents
• However many also indicated later in the
  questionnaire they did not follow any guidelines,
  they had no guidelines, or they had issues with
  the guidelines provided

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Conclusion

• Pilot study evidence a broader based study would
  be useful
• Will need a longer instrument and more follow-up
  to increase response rate
• Explore attitudes regarding guidelines