Indicators Of Drug Use Research Articles

Indications for Propensity Scores and Review of their Use in Pharmacoepidemiology

Use of propensity scores to identify and control for confounding in observational studies that relate medications to outcomes has increased substantially in recent years. However, it remains unclear whether, and if so when, use of propensity scores provides estimates of drug effects that are less biased than those obtained from conventional multivariate models. In the great majority of published studies that have used both approaches, estimated effects from propensity score and regression methods have been similar. Simulation studies further suggest comparable performance of the two approaches in many settings. We discuss five reasons that favour use of propensity scores: the value of focus on indications for drug use; optimal matching strategies from alternative designs; improved control of confounding with scarce outcomes; ability to identify interactions between propensity of treatment and drug effects on outcomes; and correction for unobserved confounders via propensity score calibration. We describe alternative approaches to estimate and implement propensity scores and the limitations of the C-statistic for evaluation. Use of propensity scores will not correct biases from unmeasured confounders, but can aid in understanding determinants of drug use and lead to improved estimates of drug effects in some settings.

Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: characteristics and results of an education intervention to ensure appropriate use

To examine the use of psychotropic drugs in 24 rural and urban long-term care (LTC) facilities, and compare the effect of an education intervention for LTC staff and family members on the use of psychotropic drugs in intervention versus control facilities. Interrupted time series with a non-equivalent no-treatment control group time series. Data on drug use were collected in 24 Western Canadian LTC facilities (10 urban, 14 rural) for three 2-month time periods before and after the intervention. Pharmacy records were used to collect data on drug, class of drug, dose, administration, and start/stop dates. Chart reviews provided demographics, pro re nata (prn) use, and indications for drug use. Subjects comprised 2443 residents living in the 24 LTC facilities during the 1-year study. An average of 796.33 residents (32.7%) received a psychotropic drug. An education intervention on psychotropic drug use in LTC was offered to intervention physicians, nursing staff, pharmacists and family members. Approximately one-third of residents received a psychotropic drug during the study, often for considerable lengths of time. A minority of psychotropic drug prescriptions had a documented reason for their use, and 69.5% of the reasons would be inappropriate under Omnibus Budget Reconciliation Act (OBRA) legislation. Few psychotropic drug prescriptions were discontinued or reduced during the study. More urban LTC residents received neuroleptics and benzodiazepines than their rural counterparts (26.1% vs. 15.7%, and 18.0% vs. 7.6%, respectively). The education intervention did not result in any significant decline in the use of these drugs in intervention facilities. The results suggest substantial use of psychotropic drugs in LTC, although rural LTC residents received approximately half the number of psychotropic drugs compared with urban residents. A resource-intensive intervention did not significantly decrease the use of psychotropics. There is a need for better monitoring of psychotropic drugs in LTC, particularly given that voluntary educational efforts alone may be ineffective agents of change.

MAPPING THE CONSEQUENCES OF AN UNANTICIPATED DRUG SUPPLY CHANGE OF UNCERTAIN ORIGINS: RESPONSE TO THE COMMENTARIES

MAPPING THE CONSEQUENCES OF AN UNANTICIPATED DRUG SUPPLY CHANGE OF UNCERTAIN ORIGINS: RESPONSE TO THE COMMENTARIES

Drug use indicators at a secondary health care facility in Lagos, Nigeria

Objective: Drug-use indicators were measured in a secondary health care facility in Lagos, Nigeria. Method: Retrospective prescribing data was used and patient records were selected using a systematic sampling method. Results:The average number of drugs per patient was 3.5=1= 1.4, 14% of patients received at least one injection and 55% of patients were prescribed at least one antibiotic. The injections were prescribed for a variety of indications where oral therapy could have been used. Antibiotics were prescribed largely for presumed infections. Conclusion: These indicators show that the level of drug use at the hospital is sub-optimal and need to be improved upon. Key Words: Drug-use; Indicators; Secondary health facilities; Lagos Journal of Community Medicine & Primary Health Care Vol.16(1) 2004: 21-24

Hair‐testing for illicit drugs

Human hair may contain deposits of illicit drugs. Testing of hair will provide an indicator of drug use at the time the hair was grown. Hair samples have several advantages over urine samples, particularly length of surveillance period (months rather than days) and resistance to tampering. Any form of drug‐testing must be seen as a component of a clinical plan for the management of the patient's drug misuse, mental disorder and offending.

The effect of an educational intervention on improving rational drug use

To evaluate the effect of an educational intervention on rational drug use amongst Primary Health Care workers in two Local Government Areas (LGAs), Mushin and Ikeja, in Lagos State. Mushin was randomly selected as the intervention LGA while Ikeja was selected as the control L.G.A. A structured educational intervention designed to improve prescribing practices was carried in Mushin LGA for four weeks. Drug use indicators were measured before, at two weeks and three months post intervention. At baseline, most of the drug-use indicators in the intervention LGA were significantly worse (p < 0.05) than the control LGA. However, at the two-week evaluation, the educational programme achieved a significant reduction in the average number of drugs in the intervention LGA from 7.3+ 2.8 to 6.3 + 2.3 (p=0.000) compared to the control LGA where there was no significant change (from 4.9+ to 4.8+2.2, p=0.647). There was also a significant increase in the percentage of patients rationally managed from 18% to 30% (p=0.0005) in the intervention LGA unlike the control LGA (from 33% to 31%,p=0.693.). The rate of change in the average number of drugs prescribed was significantly higher in the intervention LGA (+14% )compared to the control LGA (+2%,p=0.0000). The improvements were not sustained at the three-month evaluation, as most of the indicators were similar to values obtained at the baseline. The intervention programme significantly improved rational drug use in the short-term period only. Other cost effective and sustainable intervention models for improving prescribing practices should be developed.

Update on drug-related problems in the elderly

Background: Although pharmacotherapy for the elderly can treat diseases and improve well-being, its benefits can be compromised by drug-related problems. Objective: This article reviews recent publications concerning drug-related problems in the elderly, as well as articles describing the development of 3 sets of quality indicators for medication use in the elderly. Methods: Relevant articles were identified through a search of MEDLINE (2002–March 2003) for articles on drug-related problems, inappropriate prescribing, and adverse drug events in the elderly. Results: The review included 7 articles published in 2002 and 2003. A study in ambulatory elderly persons reported that ∼5.0% of patients had ≥1 adverse drug event within the previous year. Another study found that ∼20.0% of ambulatory elderly persons used ≥1 inappropriate drug, as defined by drug utilization review (DUR) criteria, with drug-disease interactions and duration of use being the most common drug-related problems. A third study involving elderly individuals in assisted living facilities found that 16.0% used ≥1 inappropriate drug, as defined by the Beers criteria. Another study examined whether inappropriate drug use, as defined by the Beers or DUR criteria, was associated with death or a decline in functional status; it found that only use of drugs defined as inappropriate by DUR criteria (particularly those drugs associated with drug-drug or drug-disease interactions) was associated with a decline in the ability to perform basic self-care. Three studies, 1 from the United States, 1 from the United Kingdom, and 1 from Canada, described consensus development of quality indicators for drug use in the elderly, including drugs to avoid, maximum daily dose, drug duplication, limits on duration of use, drug-drug and drug-disease interactions, need for drug monitoring, underuse of necessary drugs to treat or prevent common problems, and inappropriate drug-administration technique. Conclusions: Drug-related problems are common in elderly patients. Data from recently published studies provide guidance to practitioners and directions for future research.

The Cuban experience in focusing pharmaceuticals policy to health population needs: initial results of the National Pharmacoepidemiology Network (1996–2001)

In 1996, a National Pharmacoepidemiology Network was set up in Cuba in order to disseminate problem-oriented information and develop continuing education activities on drug therapy, to perform research on drug utilisation and to promote interventions to improve drug use. It is coordinated by the Centre for the Development of Pharmacoepidemiology, which is also in charge of regulatory and administrative duties and collaborates with the National Pharmaceutical Industry. By 2001, a number of educational and information initiatives had been undertaken, particularly in primary health care, which resulted in improvement of indicators of drug use. Cuba keeps good health standards in spite of a short health budget.

Angiotensin-converting enzyme (ACE) inhibitor therapy after myocardial infarction in relation to left ventricular function

Objective--To investigate to what extent and by what methods clinicians assess left ventricular (LV) function after an acute myocardial infarction (AMI) and how the results of the assessments relate to the use of angiotensin-converting enzyme (ACE) inhibitors; furthermore, to explore which main indications caused the clinicians to initiate ACE inhibitor therapy. Design--From 16 hospitals we drew a sample of patients who were discharged with the diagnosis of AMI during a 3-month period in 1999/2000. Physicians in each hospital obtained the observed rate of use of cardiovascular drugs at discharge and also information on ejection fraction (EF) measurements. The results of the EF recordings were classified into three categories: >0.50, 0.40-0.50 and <0.40. The clinicians' main indications for drug use were reported. Results--Among 767 patients discharged alive, EF was measured in 409 (53%), by echocardiography in 53% and by radionuclide ventriculography in 47%. Of the 409 patients 227 (55%) had EF >0.50, 95 (24%) EF 0.40-0.50 and 87 (21%) EF <0.40. Adjusted odds ratio for ACE inhibitor therapy being initiated during the AMI was 13.5 for those with EF <0.40 compared with those with EF >0.50. The main indication for starting ACE inhibitor therapy was heart failure (50%) followed by secondary prevention (42%). Conclusion--Measuring EF appears to be an important tool in the evaluation of AMI patients prior to discharge from hospital. Initiation of ACE inhibitor therapy related strongly to the results of the assessments.

How useful are unpublished data from the Food and Drug Administration in meta-analysis?

The goals of this systematic review and meta-analysis were to ascertain whether studies of nonsteroidal anti-inflammatory drugs (NSAIDs) summarized in the FDA reviews are ultimately published, to compare the methodologic and population characteristics of studies summarized in the FDA reviews with those reported in peer reviewed literature, and to compare the pooled relative risk of dyspepsia from NSAIDs in each data source. Summary measures of risk difference were calculated with a random effects model; meta-regression was used to assess the effect of study covariates. Among 37 studies described in the FDA reviews, one was published. Sample size, gender distribution, indication for drug use, and methodologic quality did not vary significantly between the published and FDA data. The pooled risk ratio for dyspepsia obtained using published data (1.21) or FDA data (1.07) did not differ significantly or practically. Data from FDA reviews may be a viable data source for systematic reviews and meta-analyses but only after being subjected to the same methodologic scrutiny as published data.

Patient information leaflets--helpful guidance or a source of confusion?

According to the European Community Directive 92/27, pharmaceutical companies are responsible for working out patient information leaflets (PILs) for all products marketed, and every PIL should comply with the Summary of Product Characteristics (SPC) and be phrased so that it is easily understandable by the patient. However, the volume of information included in the PIL may differ for different brands, and furthermore, the same drug may be registered for different indications. Patients may therefore receive different drug information when they renew prescriptions for the same generic drug. To examine if PILs on different brands of generically identical drugs contain inconsistent and diverging information that may lead to confusion. Case-finding among patients who contacted a pharmacy because of problems related to the information retrieved from the PIL. Inquiries to a Danish pharmacy during one year (1 June 2000-31 May 2001). Different brands of generically identical products included PILs with substantial inconsistencies. Diverging information about indications for drug use, adverse effects, drug-drug interactions and precautions and considerations concerning pregnancy and breastfeeding resulted in inquiries to the pharmacy. Patients may be confused by inconsistent information in PILs from different brands of generically identical drugs. Confusion about drug treatment may lead to reduced compliance and initiatives should be taken to coordinate information in PILs covering the same generic product.

The Trouble with Peace

The cease-fires of 1994 marked the transition of Northern Ireland toward peace. Local media, public perception, and claims by “drug authorities” suggest an increase in drug use subsequent to the cease-fires. This article suggests that social problems in Northern Ireland must be understood in the context of wider political conflict and that the conflict affects all social phenomena. Therefore, the extent and patterning of drug use in young people in Northern Ireland are explored, linked to the major cease-fires. The historical influences of the key paramilitary groups are outlined in relation to their drug ideologies. Media and professional perceptions are examined alongside available evidence constructed from multiple indicators of drug use. Our review of the evidence suggests that it is incorrect to assume that most drug use has increased since the cease-fires. One notable exception to that general conclusion is that a heroin scene may be developing in Northern Ireland.

Drug Information Systems, Early Warning, and New Drug Trends: Can Drug Monitoring Systems Become More Sensitive to Emerging Trends in Drug Consumption?

Drug Information Systems (DIS) are called upon to provide an early warning of emerging trends in drug use. However, little theoretical attention is directed toward exploring conceptual issues in this area. In this paper a typology of existing DIS is offered. Among the features that distinguish DIS are their structure (human network or organization systems) and the range of information sources used. Indicators of drug use can be placed on a continuum of sensitivity ranging from leading edge indicators to lagged indicators. Sensitivity implies volatility as sensitive indicators also react to fluctuations that do not become trends. DIS conventionally are largely reliant upon lagged indicators. What is required are DIS that combine a critical information processing function with the ongoing systematic collection of data from a range of data sources. [Translations are provided in the International s Section of this issue.]

Methods for Estimating the Number of “Hard-Core” Drug Users

This article reviews methods used to estimate the number of “hardcore” drug users. Synthetic estimation methods include the population projection method, which extrapolates from areas where prevalence is known to other areas, and the principal component method, which uses relationships observed among multiple indicators to obtain a single indicator of drug use. Small area estimations project risk estimates developed from small area surveys to larger areas, and capture-recapture methods provide reliable estimates only if the underlying assumptions are met. In making estimates, researchers should understand the limitations of the data and changes in drug use patterns. The challenge for future research is to refine each method and then to combine the strengths of each to produce the best estimates possible.

Rationality of drug prescriptions in rural health centres in Burkina Faso.

The objective of this study is to investigate the quality of drug prescriptions in nine health centres of three districts in rural Burkina Faso. 313 outpatient consultations were studied by methods of guided observation. Additionally interviews were held with the health care workers involved in the study. A total of 793 drugs prescribed by 15 health care workers during the observation period and 2815 prescribed drugs copied from the patient register were analyzed. An average of 2.3 drugs were prescribed per visit. 88.0% of the prescribed drugs were on the essential drug list. 88.4% were indicated according to the national treatment guidelines. 79.4% had a correct dosage. The study revealed serious deficiencies in drug prescribing that could not be detected by assessing selected quantitative drug-use indicators as recommended by the WHO. In two-thirds of the cases the patients received no information on how long the drug had to be taken. Errors in dosage occurred significantly more often in children under 5 years. The combined analysis of choice and dosage of drugs showed that 59.3% of all the patients received a correct prescription. Seven out of 21 pregnant women received drugs contraindicated in pregnancy. We conclude that assessment of quantitative drug-use indicators alone does not suffice in identifying specific needs for improvement in treatment quality. We recommend that prescribing for children under 5 and for pregnant women should be targeted in future interventions and that the lay-out, content and distribution of treatment guidelines must be improved.

Drug Problem Recognition among Mexican American Drug-Using Arrestees

Demographic factors, drug-use severity indicators, social resources, and personal perceptions were tested as correlates of drug-problem recognition among Mexican American drug-using arrestees. Ethnicity-related attitudes, perceptions, and experiences were among the factors tested. Multivariate regression analysis found that lifetime polydrug use and conventional moral beliefs were key deterninants of the perception that one's own drug use is a problem. Implications of these findings are cited for help-seeking and engagement in treatment by Mexican American drug users.

Development of a Manual of Indicators for Drug Use in Australian Hospitals

Indicators are measurement tools that assist healthcare practitioners to evaluate, and potentially improve, the level and quality of care and services provided to patients and other customers. For example, an indicator can measure the percentage of changes in prescribing following a pharmacy intervention.

Measurement properties of quantitative urine benzoylecgonine in clinical trials research

Psychometric data are presented which examine the validity of using the concentration of benzoylecgonine in urine, a major metabolite of cocaine, as a measure of drug use, in studies of drug abuse treatments. In such research the standard biological indicator of drug use is usually a qualitative urine drug test, which merely indicates the presence or absence of a drug or its metabolite. A quantitative (i.e. continuous) outcome measure, such as the concentration of a drug or its metabolite in a biological fluid, has substantially more statistical power than a dichotomous measure and should, therefore, prove a more sensitive measure of drug use when viewed from a measurement perspective. Data from two placebo-controlled clinical trials of fluoxetine as an adjunct to treatment for cocaine abuse are analyzed to address this issue. Results indicate that urine benzoylecgonine level is closely related to self-reports of drug use and is independent of levels of anxiety, depression and hopelessness.

Prevalence and Implications of Attention-Deficit Hyperactivity Disorder Among Adolescents in Treatment for Substance Abuse

Attention-deficit hyperactivity disorder (ADHD) is overrepresented among adults and adolescents in treatment for substance abuse. This study was designed to assess the prevalence of ADHD and to elucidate differences among adolescent substance abusers relative to ADHD symptomatology. The Wender Utah Rating Scale and the Self-Evaluation (Teenager's) Self-Report were used to evaluate childhood history of ADHD and current symptoms, respectively, and the Child Attention Problems Scale was completed by treatment program clinicians. A quantitative substance use history and a subjective substance use interview were also administered. A total of 50% of 14 females and 16 males, ranging in age from 14 to 19, met study criteria for ADHD. ADHD subjects began drug use at an earlier age, had more severe substance abuse, and had a more negative self-image prior to drug use and improved self-image with drug use. They experienced more negative affective responses related to substance use and more drug craving and attentional difficulties in treatment than control subjects. The results support a substantial comorbidity of ADHD among adolescent substance abusers, with indications of drug use for self-medication. Counseling for ADHD and medication may be indicated to improve treatment outcome and future functioning.

Drug use among a misdemeanant population

Over the past two decades, researchers studying drugs and crime have employed a variety of methods to produce findings in support of the drug-crime connection including criminal justice records, self-report surveys, and the evaluation of physical evidence through urinalysis. Using these techniques, they have been able, to demonstrate linkages between hard drugs and criminal behavior,1 make estimates of the prevalence of drug use among criminal populations, 2 specify drug trends in the general population and make forecasts of drug epidemics. 3 The purpose of this paper is not to review the extensive research on drugs and crime. It suffices to point out that although research on drug use, crime, and criminal justice has covered most of the spectrum of criminality, much of the concern, and a majority of the research and scholarship has focused on the connection between drugs and serious crime. Less attention has been given to the connection between drug use and what are frequently thought to be more minor criminal offenses. This paper attempts to expand our knowledge of drug use among populations involved in law breaking by examining some drug use indicators in a sample of felony and misdemeanor arrestees in one city, Omaha, Nebraska (pop. 339,671). In particular we will make comparisons on selected drug-use indicators for various misdemeanant subpopulations such as those arrested for DUI with those arrested for other offenses. Comparisons will also address felony populations in order to determine the extent to which they differ from misdemeanor populations. The aim is to see if drug use indicators vary between levels of seriousness.