Benzodiazepine Prescriptions Research Articles

Abstract 4140180: The Effect of Benzodiazepine Use in Patients with Atrial Fibrillation and Obstructive Sleep Apnea

Introduction: Sleep apnea is a common sleep disorder that can worsen atrial fibrillation(AF) prognosis. Benzodiazepines(BZD) are commonly prescribed for insomnia, which often accompanies sleep apnea. However, BZDs have been associated with worsening of sleep apnea due to respiratory depression, pharyngeal muscle relaxation, and increase of arousal threshold, which all may lead to prolonged hypoxia. There is little research on the effect of BZD use in AF patients with sleep apnea. Therefore, the objective of this study is to investigate the effects of BZD usage on outcomes in the AF population with sleep apnea. Methods: Data from patients with AF and sleep apnea seen at Tulane Medical Center between 2010 and 2019 was obtained from Research Action for Health Network(REACHnet), a Clinical Research Network in PCORnet®. Patients with AF and sleep apnea were divided between those with a prescription of BZD and those without BZD. These two groups were compared using the Kaplan-Meier method for time-to outcome for all-cause mortality, ischemic stroke, myocardial infarction(MI), and hospitalizations in the five years following their AF diagnosis. Cox regression analysis was used to investigate proportional hazards and control for demographics, comorbidities, and medication use. Results: There were 524 total patients included with AF and sleep apnea. Of these, 413(78.8%) were not prescribed BZDs, while 111(21.1%) were taking BZDs. Use of BZDs was associated with worse outcomes. In the no BZD and the BZD group over the 5 years following AF diagnosis, the rate of mortality was 6.1% and 12.6%(p<.001), the rate of ischemic stroke was 16% and 23.4%(p=.008), the rate of MI was 11.9% and 22.5%(p<.001), and the rate of hospitalization was 51.8% and 59.5%(p<.001), respectively. In multivariate Cox regression, use of BZD was associated with higher mortality(HR: 2.65; CI: 2.26-3.05; p=.013) and hospitalization(HR: 2.15; CI: 1.99-2.31;p<.001). Conclusion: BZD use was associated with an over 2-fold increase in all-cause mortality and hospitalizations in patients with AF and sleep apnea. This suggests that BZDs should be used with caution in this patient population, and other treatment modalities for insomnia should be considered.

Dispensing of zolpidem and benzodiazepines in Brazilian private pharmacies: a retrospective cohort study from 2014 to 2021

ObjectiveThe study aimed to evaluate Zolpidem and Benzodiazepines prescription and dispensing data in private pharmacies in Brazil from 2014 to 2021. Methods: This retrospective cohort study was carried out with retrospective open data from the Brazilian Federal Government from January 2014 to August 2021 containing medicines registered in the National Controlled Products Management System (SNGPC).ResultsBetween January 2014 and August 2021, a total of 32,441,392 sales of thirteen drugs from the z-drug and benzodiazepine classes used to treat sleep disorders were recorded in Brazil. Throughout the entire period, clonazepam emerged as the most popular drug, accounting for 29.8% of total sales. Alprazolam followed in second place with 20.6% of sales, while zolpidem came in third with 14.4%. The normal-release form of zolpidem was consistently the highest-selling variant during the evaluation period. However, the fast-acting-release form exhibited the most significant growth, indicated by a noticeable upward trend in sales since 2020. In contrast, the extended-release form of zolpidem remained stable over the years.ConclusionThe increased sales of zolpidem in Brazilian private pharmacies raise concerns about potential misuse and dependence on this drug mainly for the treatment of insomnia. The epidemic of sleeping pills arises in a scenario of expectancy of short-term amelioration of symptoms, with no correspondence in best clinical practice. Education and counseling for both healthcare professionals and the general population are essential to address this growing health concern and ensure the safe and appropriate use of medications for sleep disorders.

Prescription of benzodiazepines and antidepressants among Sami and non-Sami — How childhood violence shapes prescription patterns: the SAMINOR 2 questionnaire survey and the Norwegian prescription database

BackgroundMedication for mental health problems represents a significant proportion of overall medication use and the prescription of psychotropic medicine has increased in many western countries over the last decades. Childhood violence (CV) is strongly associated with mental health problems, which in turn may increase the likelihood of being prescribed psychotropic medication. However, the association between CV and prescription of benzodiazepines (BDZ) and antidepressants is rarely described, and no such study has been performed among the Indigenous Sami people.MethodsData from the SAMINOR 2 Questionnaire Survey (2012) was linked to the Norwegian Prescription Database. Information on filled prescriptions for BDZ and antidepressants in 2004–2019 was collected for 11,296 persons (55.8% women, 22.6% Sami). Gender-stratified chi-square tests and two-sample t-tests were used to test for differences between groups. Logistic regression was applied to investigate the association between CV and filled prescriptions for BDZ and antidepressants.ResultsDuring the 16-year study period, 16.7% of all women filled at least one prescription for BDZ. The figures were significantly lower among Sami women (14.1%) compared to non-Sami women (17.4%) (p = .003). Among all women, 23.6% filled at least one prescription for antidepressants, with no difference between ethnic groups. Filled prescriptions among men were 10.0% and 14.2%, respectively, with no difference between ethnic groups. During each year, and in total, a significantly higher proportion of women exposed to CV received at least one prescription for BDZ and antidepressants, respectively, compared to women not exposed to CV, with no differences between ethnic groups. Among men, the pattern was similar.ConclusionA lower proportion of Sami women filled prescriptions for BDZ than non-Sami women. Those who reported exposure to CV filled prescriptions for BDZ and antidepressants more often than those who did not report CV. There were no overall differences between Sami and non-Sami; the dispensing rates of antidepressants and BDZ were similar for Sami and non-Sami, and the effects of CV on the dispensing of antidepressants and BDZ were also similar. This study highlights the importance of preventing CV, and of identifying a history of CV when treating adults with mental health problems.

The association between benzodiazepine prescriptions and the risk of laxative use in schizophrenia treatment.

Constipation is one of the most common adverse effects in schizophrenia treatment, and it can sometimes cause severe gastrointestinal disease. However, the results of association studies between constipation and psychotropic medications in patients with schizophrenia are inconsistent. Therefore, we investigated the characteristics of psychotropic and laxative prescriptions at discharge in patients with schizophrenia to clarify the association between psychotropics and constipation. We analyzed the data of 139 patients with schizophrenia with or without laxative prescriptions at discharge from eight institutions in 2020. Sixty-two patients were prescribed laxatives at discharge. The prescription of benzodiazepines in the laxative use group (66.1%) was significantly higher than that in the non-laxative use group (39.0%) (p = 1.4 × 10-3), and the mean number of benzodiazepines in the laxative use group (1.2 ± 1.1/day) was significantly higher than that in the non-laxative use group (0.7 ± 0.9/day) (p = 2.6 × 10-3). Multivariate logistic regression analyses revealed that benzodiazepine prescriptions were significantly associated with laxative usage (odds ratio, 3.059; 95% confidence interval, 1.523-6.144; p = 2.0 × 10-3). Benzodiazepines may be associated with constipation in patients with schizophrenia. Therefore, clinicians should be cautious when prescribing benzodiazepines for the treatment of schizophrenia.

Antipsychotic, benzodiazepine and Z-drug prescriptions in a Swiss hospital network in the Choosing Wisely and COVID-19 eras: a longitudinal study.

Physicians frequently prescribe antipsychotics off-label to treat, among others, insomnia and anxiety. The Swiss "smarter medicine - Choosing Wisely" campaign has tried to raise awareness about the risks and to limit benzodiazepine and Z-drug prescriptions. In the Italian-speaking part of Switzerland, our network of public hospitals joined the campaign with the aim of avoiding unnecessary benzodiazepine and Z-drug treatments, with prescription monitoring, benchmarking and educational contributions. Considering the risks of a possible shift towards the prescription of antipsychotics, and aware of the potential role of the COVID-19 pandemic, we decided to analyse the prescription trends of antipsychotics and benzodiazepines/Z-drugs before, during (2016-2017) and after the intervention. For this longitudinal study, we reactivated a continuous monitoring of inpatient benzodiazepine/Z-drug and antipsychotics prescriptions/deprescriptions, paused in 2018 after the end of the internal Choosing Wisely campaign, based on routinely collected observational health data. We screened all demographic, administrative and prescription data of patients admitted to the internal medicine department of the four teaching hospitals (H1-H4) belonging to the EOC (Ente Ospedaliero Cantonale) network, from the fourth quarter of 2014 to the second quarter of 2023. We analysed 74,659 hospital stays (14,645 / 16,083 / 24,285 / 19,646 at hospitals H1 / H2 / H3 / H4 respectively). The mean (± SD) case mix (a metric that reflects the diversity, complexity and severity of the treated patients) and patient age were 1.08 ± 0.14 and 73 ± 2 years. 10.6% and 12.1% of patients received antipsychotics prior to admission and at discharge respectively (new prescriptions 3.3 ± 0.7%; deprescriptions 13.3 ± 5.2%). New prescriptions showed an upward trend, with +0.20% per year (p <0.001). Patients admitted with ongoing antipsychotics therapy increased 0.36% per year (p <0.001). New benzodiazepine/Z-drug prescriptions showed a 0.20% per year decrease (p = 0.01). Patients admitted with ongoing benzodiazepine/Z-drug therapy decreased 0.32% per year (p <0.001). New antipsychotics prescriptions showed differences between hospitals, with H3 above and H2 below the average. The increase in antipsychotics quantitatively matched the decrease in benzodiazepine/Z-drug prescribing, suggesting a shift from one to the other sedative therapy. The same trend was visible in the ongoing prescriptions at admission revealing a similar out-of-hospital approach. This suggests a change in sedative prescribing strategy rather than the choice of alternative, non-pharmacological approaches. Furthermore, the variation between similar services of different hospitals points out the consequences of local prescribing cultures and the importance of continuously monitoring and benchmarking medication prescriptions.

Association of Psychotropic Prescriptions With Non-Registered Indications and the Risk of Mortality in Older Adults: A Danish Nationwide Cohort Study.

Psychotropic drug use is common in older adults, with off-label use reported despite limited understanding of the safety outcomes compared to on-label use. Incomplete recordings of treatment indications in the Danish National Prescription Register (DNPR) raise concerns about potential off-label medication use, particularly among older adults. We, therefore, investigated the association between psychotropic prescriptions with non-registered indications in DNPR and the 1-year all-cause mortality in older adults, including subgroups with any psychiatric disorders, depression, or dementia. Register-based cohort study following all older adults (≥ 65) who redeemed a first-time (since 1995) prescription of either antidepressants, antipsychotics, or benzodiazepine during 2006-2017. Redemption of a prescription with non-registered indications in the DNPR was the exposure. The outcome, 1-year all-cause mortality was analyzed using Poisson regression, estimating incidence rate ratios with 95% confidence intervals, adjusting for socio-demographics and clinical factors. 32% of prescriptions filled by 202,067 individuals for antidepressants, 37% of 97,387 for antipsychotics, and 22% of 130,471 for benzodiazepines had non-registered indications. No significant differences in mortality rates were found for antidepressants and antipsychotics with non-registered indications, while higher mortality rates were associated with benzodiazepines, mitigated when excluding individuals receiving intravenous administrations representing end-of-life treatment. The results remained consistent in subgroup analyses in patients with any psychiatric disorders, depression, or dementia and further stratified analyses by sex and age. We found that while psychotropic prescriptions with non-registered indications in DNPR were prevalent in older adults, they were not associated with excess mortality.

Association of Benzodiazepine Prescription With Short-Term Prognosis in Elderly Patients Attended in Emergency Department: Results From the EDEN PROJECT.

Benzodiazepine prescription is a growing phenomenon among the elderly population. However, information related to the frequency of these drugs among the elderly population attending in emergency departments (ED) and its impact over prognosis is scarce. The aim of this study is to assess the prevalence of benzodiazepine prescription and to analyze its association with short-term prognosis in elderly patients attended in ED. A retrospective analysis of the EDEN (Emergency Department Elderly in Need) cohort was conducted. This registry included all elderly patients attending in 52 Spanish EDs for any condition, between April 1st and 7th in 2019. Socio-demographic data, comorbidities, and medication were recorded by consulting the patient's electronic health records. The assessed outcomes consisted on new ED visit, hospitalization, and mortality at 30 days after the first ED visit, associated with the use of benzodiazepines at baseline in comparison with no prescription of benzodiazepines. Crude and adjusted logistic regression analyses including patient's comorbidities were performed. Two sensitivity analyses were performed considering concomitant prescription of other central nervous system depressants as well as direct discharge from the ED. 25 557 patients were evaluated (mean age 78 [IQR: 71-84]). 7865 (30.8%) patients were taken benzodiazepines at admission. After adjustment for comorbidities and other central nervous system drugs, benzodiazepine prescription was associated with ED revisit [OR: 1.10 (95%CI: 1.03-1.18)]. Similar results were found in the sensitivity analysis, eliminating patients with central nervous depressors [OR: 1.11 (1.03-1.25)] and patients discharged to home [OR: 1.13 (1.04-1.23)]. No association was found between the use of these drugs and new hospitalizations [OR: 0.90 (0.77-1.05)] or mortality 30 days after discharge [OR: 1.01 (0.88-1.18)]. The results held for all three outcomes in the sensitivity analyses. The use of benzodiazepines is a frequent phenomenon among the elderly population attended in the ED, being associated with an increased risk of new visits to the emergency room, but not with an increased risk of 30-day hospitalization or mortality.

Characteristics of incident benzodiazepine recipients among US veterans with posttraumatic stress disorder.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. While benzodiazepine prescribing among veterans with posttraumatic stress disorder (PTSD) declined substantially in the Veterans Health Administration over the past decade, little is known about current incident prescribing. Our objective was therefore to describe patient, provider, facility, and prescribing characteristics among veterans with PTSD who were incident benzodiazepine recipients in 2022 and contrast these to the characteristics for incident recipients in 2012. This retrospective observational study included all veterans with PTSD who received an incident benzodiazepine prescription during calendar year 2022 and separately for 2012. The distribution of patient, provider, facility, and benzodiazepine prescribing characteristics was contrasted between years. Stratified subanalyses were conducted by potential non-PTSD benzodiazepine indication, including anxiety and sleep disorders. A total of 28,310 (6.6%) incident benzodiazepine recipients were identified in 2012, which decreased to 16,776 (1.9%) incident recipients in 2022. The proportion of initial prescriptions written for a days' supply of 30 or more days decreased from 75.6% to 51.7%, and the proportion who received a second prescription within 6 months decreased from 68.7% to 53.5%. The proportion of patients with diagnoses for potential benzodiazepine indications also increased, including for generalized anxiety disorder (15.1% increase), obsessive compulsive disorders (0.6% increase), panic disorder (6.7% increase), and sleep disorders (22.9% increase). As incident benzodiazepine prescribing among veterans with PTSD decreased over the past decade, so did the volume of drug dispensed and duration of therapy, while the prevalence of documented prescriptions for non-PTSD indications increased.

Benzodiazepine Utilization in Ischemic Stroke Survivors: Analyzing Initial Excess Supply and Longitudinal Trends.

Benzodiazepines are commonly prescribed for post-acute ischemic stroke for anxiety, insomnia, and agitation. While guidelines discourage use in those aged ≥65 years, little is known about prescription patterns at the national level. We analyzed a 20% sample of US Medicare claims from April 1, 2013, to September 30, 2021. We selected beneficiaries aged ≥65 years discharged alive following an acute ischemic stroke who had traditional Medicare coverage and 6 months' prior enrollment in Parts A (hospital insurance), B (Medical insurance), and D (drug coverage). We excluded those with prior benzodiazepine prescriptions, self-discharges, or discharge to skilled nursing facilities. We examined demographics, comorbidities, first prescription days' supply, cumulative incidences of benzodiazepine first prescription fills within 90 days after discharge, and geographic and yearly trends. We included 126 050 beneficiaries with a mean age of 78 years (SD, 8); 54% were female and 82% were White. Within 90 days, 6127 (4.9%) initiated a benzodiazepine. Among new prescriptions, lorazepam (40%) and alprazolam (33%) were the most prescribed. Most (76%) of first fills had a day's supply over 7 days and 55% between 15 and 30 days. Female initiation rates were higher (5.5% [95% CI, 5.3-5.7]) than male initiation rates (3.8% [95% CI, 3.6%-3.9%]). Rates were highest in the southeast (5.1% [95% CI, 4.8%-5.3%]) and lowest in the midwest (4.0% [95% CI, 3.8%-4.3%]), with a modest nationwide initiation decline from 2013 to 2021 (cumulative incidence difference, 1.6%). Despite a gradual decline in benzodiazepine initiation from 2013 to 2021, we noted excessive supplies in prescriptions post-acute ischemic stroke discharge, underscoring the need for improved policies.

Clinical Outcomes of Benzodiazepine Prescribing for People Receiving Opioid Agonist Treatment: A Systematic Review of the Evidence.

Many countries are experiencing an increased use of unregulated benzodiazepines in combination with opioids and other drugs, which contributes to drug-related harm. This descriptive review identifies and synthesises the outcomes of studies co-prescribing benzodiazepines and opioids. A systematic review was undertaken in Medline, CINAHL, PsychInfo, Embase, and the Cochrane databases covering publications from 1 January 1991 to 18 November 2021. Inclusion criteria were peer reviewed, English language studies of adults prescribed opioid agonist treatment (OAT) and a concurrent benzodiazepine, and reporting outcome data. Of the 4370 titles screened, 18 papers were included. The main outcomes identified covered all-cause mortality (ACM) (n = 5); overdose death (n = 3); retention in treatment (n = 7); and hospitalisation/emergency department encounters (n = 2). Other outcomes included QTc interval, cognitive function, illicit drug use, and mental health. The prescription of benzodiazepines alongside OAT increased the ACM by 75-90%, while evidence on overdose death was less robust but indicative of increased risk (40-334%). There was an indicative positive effect on treatment retention, with increased retention in those prescribed a benzodiazepine with OAT compared to those not prescribed or taking non-prescribed benzodiazepines. In conclusion, methodologically robust epidemiological studies found increased ACM and overdose death but possibly improved retention. However confounders (e.g., psychiatric comorbidity) exist, so a trial is recommended.

Long-term opioid prescribing and the incidence of opioid-related hospitalizations or emergency department visits among patients with metastatic cancer.

200 Background: Many patients with metastatic cancer experience cancer-related pain which is commonly managed using opioids. Although opioids are an effective tool for cancer pain management, their use can result in adverse effects which may be related to long-term use and are understudied in this population. Therefore, we aimed to describe long-term opioid prescribing (LTOP) practices among patients with metastatic cancer and investigate the incidence of opioid-related hospitalizations and emergency department (ED) visits among recipients of long-term prescribing. Methods: This retrospective cohort study used population-based data from Alberta, Canada to identify patients diagnosed with stage IV cancers between 2004-2017 who had at least 1-year of follow-up and were opioid naïve at diagnosis. LTOP was defined as receipt of a ≥90-day supply of opioids with less than a 30-day gap in supply within a 180-day period. Prescribing practices were characterized according to timing (early vs. end-of-life [EoL] onset), morphine equivalent dose, duration, and concurrent medication use. The EoL phase of disease was defined as the year preceding death. The incidence rate of opioid-related encounters was compared between different characteristics of LTOP. Results: The study included a total of 10927 patients, 2521 (23%) of whom received long-term opioid prescribing after diagnosis. LTOP became more common as patients approached EoL, with most patients (53%) having LTOP initiated only within their last year of life. 85 patients (3.4%) experienced an opioid-related hospitalization or ED visit after initiation of LTOP, with an incidence rate of 2.36 (95% CI 1.92, 2.86) encounters per 100 person-years. Higher opioid dosage and concurrent prescribing of anxiolytics, benzodiazepines, antidepressants, and neuroleptic medications were significantly associated with a higher incidence of opioid-related encounters. Conclusions: Long-term opioid prescribing is commonly experienced by patients living with metastatic cancer as a chronic disease. The concurrent use of psychoactive drugs during LTOP was associated with experiencing opioid-related hospitalizations/ED visits.

Impacto da farmácia verde de Ipatinga – MG na redução das prescrições de Benzodiazepínicos em unidades de saúde pública.

Phytotherapy as a therapeutic alternative is the context of the study on Anxiolytic Herbal Medicines in the reduction of Benzodiazepine prescriptions (BZDs). The verification was developed from the analysis of the quantity dispensed with BZDs compared to the dispensing of anxiolytic Herbal Medicines from the Green Pharmacy of Ipatinga - MG. The data correspond to the dispensations, year-on-year from 2013 to 2019, in ten Health Units with phytotherapy. Clonazepam 2.5 mg/ml and Diazepam 10 mg are BZDs. Lavender Tincture, Chamomile, Holy Grass, Passion Fruit and Melissa; correspond to anxiolytic Herbal Medicines. From 2013 to 2017, the dispensation of anxiolytic herbal medicines increased by an average of 12.686% while BZD prescriptions reduced by an average of 6.957%. The trend was interrupted with the ban of the Green Pharmacy by the health surveillance, in August 2018. The objective is to verify the impact of anxiolytic Herbal Medicines in the reduction of BZDs prescriptions in Health Units with phytotherapy in Ipatinga - MG, within the Scope of SUS.

The Effect of Opioids and Benzodiazepines on Exacerbation Rate and Overall Survival in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Non-Invasive Ventilation.

Background: There is a growing concern that opioids and benzodiazepines can depress the respiratory drive and could contribute to worsening respiratory failure and higher exacerbation frequency in COPD. However, the relationship between the exacerbation rate and medication taken is poorly understood in patients with chronic respiratory failure due to COPD. Methods: As part of a service evaluation project, we analysed 339 patients with COPD who were established on long-term non-invasive ventilation (LT-NIV) at our tertiary centre. We investigated the relationship between benzodiazepine and opioid prescription and clinical outcomes as well as their impact on the exacerbation rate and overall survival following setup. Results: Before LT-NIV setup, 40 patients took benzodiazepines and 99 patients took opioids. Neither benzodiazepine nor opioid use was associated with changes in daytime blood gases, overnight hypoxia or annual exacerbations before NIV setup, but patients taking opioids were more breathless as assessed by modified Medical Research Council scores (3.91 ± 0.38 vs. 3.65 ± 0.73, p < 0.01). Long-term NIV significantly reduced the number of yearly exacerbations (from 3.0/2.0-5.0/ to 2.8/0.71-4.57/, p < 0.01) in the whole cohort, but the effect was limited in those who took benzodiazepines (from 3.0/2.0-7.0/ to 3.5/1.2-5.5/) or opioids (3.0/2.0-6.0/ to 3.0/0.8-5.5/). Benzodiazepine use was associated with reduced exacerbation-free survival and overall survival (both p < 0.05). However, after adjustment with relevant covariates, the relationship with exacerbation-free survival became insignificant (p = 0.12). Opioids were not associated with adverse outcomes. Conclusions: Benzodiazepines and opiates are commonly taken in this cohort. Whilst they do not seem to contribute to impaired gas exchange pre-setup, they, especially benzodiazepines, may limit the benefits of LT-NIV.

Self-reported benzodiazepine use among adults with chronic spinal cord injury in the southeastern USA: associations with demographic, injury, and opioid use characteristics

Study designCross-sectional cohort study.ObjectivesTo examine: (1) the self-reported frequency of specific prescription benzodiazepine use, (2) concurrent benzodiazepine and opioid use, and (3) sociodemographic, SCI, and opioid use factors associated with frequent benzodiazepine use.SettingCommunity.MethodsParticipants included 918 community dwelling adults with chronic ( > 1 year) traumatic SCI originally identified from a specialty hospital or a state-based surveillance system. Self-reported frequency of specific prescription benzodiazepines and opioids used, concurrent use, and factors associated with use were assessed.ResultsTwenty percent reported any benzodiazepine use in the past year and 13% reported at least weekly use. Concurrent daily or weekly use of benzodiazepines and opioids was reported by 6.5%, with those individuals taking an average of 1.1 (0.4) benzodiazepines and 1.4 (0.6) opioids. Compared to younger adults, those 50–65 years old had lower odds of at least weekly benzodiazepine use (OR = 0.50, 95% CI, 0.29–0.89, p-value = 0.02). Non-Hispanic Blacks reported lower use of benzodiazepines compared to non-Hispanic whites (OR = 0.32, 95% CI, 0.15–0.68, p-value = <0.01). Weekly opioid use was associated with higher odds of using benzodiazepines (OR = 3.10, 95%CI, 1.95–4.95, p-value = <0.01).ConclusionsBenzodiazepine use was commonly reported among those with SCI. Despite the potential risks, a high portion of those who reported benzodiazepine use also reported prescription opioid use. The findings highlight the need for monitoring of prescription medication use to avoid potentially risky concurrent use and adverse outcomes.

Four-year evaluation of drug-impaired driving drug concentrations.

Drug-impaired driving is a significant public health and safety concern in the USA. To help assess current patterns of drug use in drivers, we evaluated 4 years of drug positivity in a large cohort of suspected impaired drivers. Samples collected between January 2017 and December 2020 were tested via a method compliant with the National Safety Council's Alcohol, Drugs, and Impairment Division's Tier I scope of recommended drugs. In 2017, NMS Labs received 17 346 driving under the influence of drugs cases, 17 471 in 2018, 19 050 in 2019, and 16 539 in 2020. The most common drug class detected was cannabinoids in ∼50% of the cases each year. The most common drugs detected over the 4 years were delta-9 tetrahydrocannabinol (delta-9 THC), ethanol, amphetamine/methamphetamine, fentanyl, and alprazolam. Delta-9 THC increased in positivity over the study, having been identified in 45% of cases in 2017, 46% in 2018, 46% in 2019, and 49% in 2020. Ethanol was found in 59% of cases in 2017, 59% in 2018, 61% in 2019, and 53% in 2020. Delta-9 THC and ethanol were the most common drug combination, found together in ∼19% of the cases every year of the study. Statistically significant increases in the average concentration of the following drugs were observed: fentanyl (5.7 ng/mL in 2017 to 9.6 ng/mL in 2020), methamphetamine (301 ng/mL in 2017 to 381 ng/mL in 2020), and delta-9-THC (6.4 ng/mL in 2017 to 7.3 ng/mL in 2020). Other findings included increases in the maximum reported concentrations between 2017 and 2020 for amphetamine (1400 to 2700 ng/mL), methamphetamine (5550 to 13 000 ng/mL), and fentanyl (56 to 310 ng/mL). Statistically significant concentration decreases were noted for several central nervous system depressants, notably prescription benzodiazepines, and several prescription narcotic analgesics.

The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing.

The aims of this study were to measure the prevalence of polypharmacy and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. This was a multinational retrospective cohort study across six countries: Belgium, France, Germany, Italy, Spain and the UK. We used anonymized longitudinal patient-level information from general practice databases hosted by IQVIA. Patients ≥65 years were included. Polypharmacy was defined as having 5-9 and ≥10 distinct drug classes (ATC Level 3) prescribed during a 6-month period. Selected medications were: opioids, antipsychotics, proton pump inhibitors (PPI), benzodiazepines (ATC Level 5). We included country experts on the healthcare context to interpret findings. Age and gender distribution was similar across the six countries (mean age 75-76 years; 54-56% female). The prevalence of polypharmacy of 5-9 drugs was 22.8% (UK) to 58.3% (Germany); ≥10 drugs from 11.3% (UK) to 28.5% (Germany). In the polypharmacy population prescribed ≥5 drugs, opioid prescribing ranged from 11.5% (France) to 27.5% (Spain). Prescribing of PPI was highest with almost half of patients receiving a PPI, 42.3% (Germany) to 65.5% (Spain). Benzodiazepine prescribing showed a marked variation between countries, 2.7% (UK) to 34.9% (Spain). The healthcare context information explained possible underreporting for selected medications. We have found a high prevalence of polypharmacy with more than half of the older population being prescribed ≥5 drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, worryingly high usage of PPIs and benzodiazepines supports current efforts to improve polypharmacy management across Europe.

Benzodiazepine Adverse Reaction Cases Age 50 and Older Reported to the U.S. Poison Centers: Healthcare Use and Major Medical Effects

Background: Despite widespread consensus on the need to reduce benzodiazepine (BZD) use in older adults, prescription rates in the U.S. have paradoxically increased over the past few decades. Objective: We examined (1) the characteristics of the BZD adverse reaction cases in patients aged 50 and older that were admitted to a healthcare facility (HCF) and experienced major effects/death, and (2) the associations between the concomitant use of opioids and/or antidepressants and HCF admission and major effects/death among BZD cases. Methods: We used the 2015–2022 National Poison Data System (NPDS), which contained data from 55 America’s Poison Centers. We fitted two multivariable logistic regression models to examine the associations between the co-use of opioids and/or antidepressants and HCF admission and major effects/death. Results: Of the BZD cases that were examined (N = 1979), 14.9% or 295 cases were admitted to healthcare facilities, and 8.5% of those who were followed up (77 out of 893 cases) experienced major effects or death. The number of co-used substances, co-use of opioids and antidepressants, atypical antipsychotics, anticonvulsants, muscle relaxants, and Gabapentin were associated with greater odds of healthcare admission. Co-use of opioids and healthcare admission were associated with greater odds of major effects/death. Conclusions: Adverse reactions and healthcare admissions are likely to be prevented when healthcare providers limit and carefully monitor BZD prescribing, especially for those who are on other medications, including prescription opioids and antidepressants.

Evaluation of prescribing patterns of switching to and add-on lemborexant in patients treated with hypnotic medication: a nationwide claims database study in Japan

ABSTRACT Background When considering changing hypnotic pharmacotherapy, lemborexant has attracted attention as a candidate due to its effectiveness and safety profile. However, few studies have investigated switching patterns in clinical practice. Research design and methods We conducted a retrospective cohort study using a nationwide claims database. Patients prescribed a single hypnotic who either subsequently switched to (switching cohort) or were additionally prescribed (add-on cohort) lemborexant between July 2020 and December 2021 were identified. Proportion of successful switching was defined as remaining on lemborexant alone or without any hypnotic at 6 months after lemborexant initiation. Results The success proportion was 70.1% in the switching cohort (n = 4,861) and 38.6% in the add-on cohort (n = 9,423). In the add-on cohort, the success proportion was lower in patients with a hypnotic history of ≥180 days (31.4%) and in patients whose prescribed hypnotic was a benzodiazepine or non-benzodiazepine (31.5% and 37.6%, respectively). Conclusion The proportion of successful switching was higher in patients who switched to lemborexant than in those who added lemborexant as a concomitant treatment. The lower success proportion in the add-on cohort might be related to clinically more severe insomnia, and/or a concomitant prescription of benzodiazepine or non-benzodiazepine, from which discontinuation may be challenging.

Brief Report: A population-based study of the impact of the COVID-19 pandemic on benzodiazepine use among children and young adults.

The COVID-19 pandemic was associated with increases in the prevalence of depression and anxiety among children and young adults. We studied whether the pandemic was associated with changes in prescription benzodiazepine use. We conducted a population-based study of benzodiazepine dispensing to children and young adults ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in prescription benzodiazepine dispensing occurred, and interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected benzodiazepine use. A structural break occurs where there is a sudden change in the trend of a time series. We observed an immediate decline in benzodiazepine dispensing of 23.6 per 100,000 (95% confidence interval [CI]: -33.6 to -21.2) associated with a structural break in April 2020, followed by a monthly decrease in the trend of 0.3 per 100,000 (95% CI: -0.74 to 0.14). Lower than expected benzodiazepine dispensing rates were observed each month of the pandemic from April 2020 onward, with relative percent differences ranging from - 7.4% (95% CI: -10.1% to - 4.7%) to -20.9% (95% CI: -23.2% to -18.6%). Results were generally similar in analyses stratified by sex, age, neighbourhood income quintile, and urban versus rural residence. Further research is required to understand the clinical implications of these findings and whether these trends were sustained with further follow-up.

Assessing Decision Fatigue in General Practitioners' Prescribing Decisions Using the Australian BEACH Data Set.

General practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday. This study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics. Among 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines. GPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior. We found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications.