Epidemiology of Benzodiazepine Prescribing and Use

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Epidemiology of Benzodiazepine Prescribing and
Use

• 5nd Annual Benzodiazepine Study Group Conference
• Portland, Maine
• 2007

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Marcella H. Sorg, PhD, RN Margaret Chase Smith
Policy Center University of Maine
J. Gerry Mugford, PhD, CMH Asst. Prof. of
Medicine, Pharmacy, Psychiatry Memorial
University of Newfoundland
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Credit Where Credit is Due

• Stevan Gressitt, MD
• Office of Substance Abuse, State of Maine
• Office of Chief Medical Examiner (Maine, New
  Hampshire, Vermont)
• Health Environmental Testing Lab, Maine DHS
• All contributors to Maine Benzodiazepine Study
  Group data collection

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Focus on Research

• Why more numbers??
• Build effective feedback loops between practice
  and policy to change behavior
• INFORMATION SYSTEMS
• Monitor change
• CONTEXT PLAYERS CHANGING

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History

• Maine Benzodiazepine Study Group created in 2002
  collecting data
• 6th. year of data
• 5th. year of Annual Benzodiazepine Study Group
  Conferences

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Epidemiology

• Increased morbidity in particular populations
  suggests
• Potential need to screen treat underlying
  problem
• Variation in clinical prescribing practices
• Potential need to set guidelines
• Individual and public health risks of
  prescriptive misuse prevalence
• Potential need to regulate

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Prevalence of Benzodiazepine Prescribing Use

• What numbers are meaningful?
• Differences between subpopulations
• Jurisdictions or cultures with higher use
• Age groups with higher use
• Gender differences
• What do such differences mean?
• Increased rates of anxiety/insomnia in specific
  population?
• Differences in clinical prescribing practices?
• Variation in patterns of misuse

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Context of study includes prescription drug abuse
generally
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Conceptual Framework Inputs

• Increasing use of pharmaceuticals
• Industry growth
• Direct-to-consumer advertising
• Mandate to treat pain aggressively
• Shortened time for therapeutic encounters
• Aging population and rising prevalence of chronic
  disease
• Combinations substitutions with illicit drugs
• Reduced isolation of rural areas

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What Patterns are Consistent?

• Prescriptions
• Females gt males
• Older gt younger, generally, with peak in 50s
• Associated risks
• Accidents falls, motor vehicle
• Polypharmacy adverse events
• Suicides (multiple drug)
• Illicit drug use (associated with opiates,
  alcohol)
• Drug dependency with long-term use

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Prescription Drugs in 2006 Benzodiazepines

• Among the most common street drugs
• 34 of prescriptions for scheduled drugs in Maine
  FY2004 to FY2006 (gt 600,000/year)
• 68 for persons older than 45, predominantly
  female
• 5 of seized samples tested (3 in 2005)
• 15 of drug-induced deaths (incl. 9 multiple
  drug toxicity with BZD toxicology)

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Anxiolytic
Amnesic
Hypnotic
BZD Uses
Myorelaxant
Anticonvulsant
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Is there a problem?

• Women more likely than men to have
  prescriptionwhy? (genders more equal for
  emergency room, suicides)
• Higher prescribing rates for Medicare/Medicaid
  why?
• Older age has rates gt 2X general population for
  prescriptions (younger ages for emergency room)
• 24 increase in hip fracture comparing seniors
  take BDZ vs. no BDZ

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Baseline Data Collected by the MBSG
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12.8 of enrollees
12.5 of enrollees
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Express Scripts 2002 (2003)N 206,675 n RS
4,993
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Anthem 2003 Highlights

• 10 of 2003 subscribers with prescriptions had at
  least 1 prescription for a BZD (n27,308 out of
  276,101)
• Of those with a BZD prescription
• 4 had a prescription for more than one type
• 16 had a prescription for gt180 days
• 67 of subscribers with a BZD scrip were female
  (similar across age groups 15)

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Note about Express Scripts

• Express Scripts states 2003 rates are unlikely to
  be significantly different from 2002
• From sample n8267 3.3
• Population size is 206,675 (possibly includes
  subscribers without any prescriptions)
• Possibly does not cover all BZDs (Anthem 10)

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The Survey Questions

• Age categories
• Sex categories
• Benzodiazepine categories
• Diagnostic information
• Perennial problem ....the denominator

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MBSG Contributions

• Univ. Maine Drug Alcohol Research Program data
  contributions involving benzodiazepines
• Office of Chief Medical Examiner (ME,NH,VT)
• Office of Substance Abuse (ME)
• Health Environmental Testing Laboratory (ME)
• Methadone Clinic Urine Tests
• Outpatient Youth Mental Health
• VT Dept of Corrections

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Prescribing Rate 7
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Is there a problem?

• Associated with illicit drug use
• Associated with substance abuse
• Associated with suicidal overdose
• Associated with automobile accidents BDZ
  established main cause
• Associated with drug overdose BDZ established
  cause

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National Data
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Drug Abuse Warning Network

• 2004
• Benzodiazepines, such as alprazolam (34)
  clonazepam (18) were each present in at least
  100,000 visits involving non-medical use of
  pharmaceuticals 29 of estimated visits
• 23 alone- single drug
• 77 poly drug
• 30 as one of two drugs
• 47 as one of three or more
• 28 with alcohol
• Age structure 18 12-20 36 21-34 35 35-54
  10 55

• 2005
• Benzodiazepines the most prevalent
  psychotherapeutic, alprazolam 36 clonazepam
  18
• 29 of non-medical use of pharmaceuticals
• Increased 19 from 04 to 05

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MYDAUS Current non-medical use of prescription
drug in last 30 days
Youngermore decrease
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DAWN Mortality

• Benzodiazepines are in the top 5 involved in
  drug-related deaths in 29/32 metro areas and 5/6
  states
• Among suicides, benzodiazepines rank first 1/32
  metro areas and among the top 5 in 19/32 metro
  areas and 2/6 states

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Benzodiazepines in Emergency Department Visits
(DAWN, US, 2002)

• Over 100,000 drug abuse-related emergency
  department visits involving BZDs in 2002
• 41 increase since 1995
• 78 involve more than one drug
• Approx. half are suicide attempts
• Visits increasing for BZD
• Dependence
• Psychic effects
• NOTE THAT DAWN CHANGED-CANT COMPARE

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Benzodiazepines in US Emergency Department
Visits, 2002

• AGE
• Highest rate 26-44
• Lowest rate 12 17 and 55
• Greatest increase since 1995 age 18-19
• GENDER
• No gender differences in rates (N.B.)
• Not sure why

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Benzodiazepines in US Emergency Department
Visits, 2002

• Most frequent Pattern continues
• Alprazolam Xanax
• Clonazepam Klonopin,Clonopin
• 78 involved gt 1 drug Pattern continues
• Substances most often reported with BZDs Pattern
  continues
• Narcotic analgesics
• Alcohol
• Marijuana

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Large increase beginning in early 2000s
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DAWN US 2004

• 106 million ED visits. during 2004
• 1,997,993 were drug-related about 2
• Nearly 1.3 million associated with drug misuse or
  abuse (Most)
• 30 involved illicit drugs only,
• 25 involved pharmaceuticals only,
• 15 involved illicit drugs and alcohol,
• 8 involved illicit drugs with pharmaceuticals,
  and
• 14 involved illicit drugs with pharmaceuticals
  and alcohol.

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ED Visits Related to Pharmaceutical Misuse/Abuse,
2004

• gt 56 of suicide-related visits included
  psychotherapeutic agents, such as benzodiazepines
  or antidepressants
• Alprazolam in 49,842 visits
• Clonazepam in 26,238 visits
• Diazepam in 15,733 visits
• Lorazepam in 16,926 visits
• 37,081 visits BZS no specific ingredient named

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Treatment Admissions
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Maine TDS 2004-2005 Unduplicated Clients
Admitted for Primary Problem of Benzodiazepines
Compared with all TDS Clients Admitted (N125)
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Maine TDS 2004-2005 Unduplicated Clients
Admitted for Primary Problem of Benzodiazepines
Compared with all TDS Clients Admitted (N125)
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2004
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Deaths
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Maine Drug-Induced Deaths
647 INCREASE
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DeathsPharmaceutical-Induced/Related Others
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Maine Drug-Related Deaths

• About one-third have BZD in their toxicology
  reports
• About 12 have BZD cause of death
• NH 20
• VT 13
• NC 2
• Another 5 have polydrug cause with BZD
  toxicology

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Benzodiazepine Deaths 2002-2005

• 67 BZD deaths
• 12 of deaths, 17 including mixed drug with
  BZD present in toxicology
• 4 (6) caused by BZD alone
• 63 (94) caused by BZD other drugs or alcohol
• 61 narcotics (49 methadone, 18
  morphine/heroin)
• 9 with alcohol
• 6 with cocaine
• 33alprazolam 36diazepam

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Problem of small numbers
35 (21)
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Whats the Problem???
Visible, Indirect Indicators
Deaths, ED Visits, Treatment Admissions,
Falls, Motor Vehicle Accidents, Lost Days at Work
Practice Guidelines, Professional Culture,
Prescription Monitoring, Medical Reimbursement
Timing for a Therapeutic Visit, Patient
Provider Education
Less Visible, More Direct, Harder to Measure
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PANDORAS BOX

• Prescribing issues
• Unnecessary
• Not the best drug
• Too long
• No alternative
• Un-used meds
• Multiple providers
• Lack of knowledge

• Diversion issues
• Drug dealing
• Drug sharing

• Pharmacology issues
• Drug interactions
• Polypharmacy

• Policy issues
• Controlled substance?
• Prescription monitoring
• Disposal unused meds

• Law enforcement issues
• Officer knowledge
• Punishment
• Perceived severity

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Pharmaceutical Misuse Abuse

• Must be examined in combination with illicit drug
  abuse
• Multiple forms
• Adverse reactions when taken as prescribed
• Accidental or intentional misuse dose, timing,
  combination with other substances (alcohol)
• Self-medication using drugs w/o prescription
• Abuse to alter mood (incl. recreational use)

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Conclusions

• Diversion probably increasing (poisonings)
• Not well monitored in law enforcement
• Great variation between states (deaths,
  treatment)
• Mortality risk is rising with polypharmacy use
• Prescribers play a central role