Sedative-hypnotic Use Research Articles

Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.

The Centers for Disease Control and Prevention recognizes Medicaid as a high-risk population for fatal opioid overdose. Further research is needed to identify factors that put Medicaid patients at increased risk. To determine whether patterns of opioid use are associated with risk of opioid-related mortality among opioid users. This is a retrospective cohort study. In total, 150,821 noncancer pain patients aged 18-64 years with ≥1 opioid prescription, April 2006 to December 2010, Washington Medicaid. Average daily dose (morphine equivalents), opioid schedule/duration of action, sedative-hypnotic use. Compared with patients at 1-19 mg/d, risk of opioid overdose death significantly increased at 50-89 mg/d [adjusted hazard ratio (aHR), 2.3; 95% confidence interval (CI), 1.4-4.1], 90-119 mg/d (aHR, 4.0; 95% CI, 2.2-7.3), 120-199 mg/d (aHR, 3.8; 95% CI, 2.1-6.9), and ≥200 mg/d (aHR, 4.9; 95% CI, 2.9-8.1). Patients using long-acting plus short-acting Schedule II opioids had 4.7 times the risk of opioid overdose death than non-Schedule II opioids alone (aHR, 4.7; 95% CI, 3.3-6.9). Sedative-hypnotic use compared with nonuse was associated with 6.4 times the risk of opioid overdose death (aHR, 6.4; 95% CI, 5.0-8.4). Risk was particularly high for opioids combined with benzodiazepines and skeletal muscle relaxants (aHR, 12.6; 95% CI, 8.9-17.9). Even at opioid doses 1-19 mg/d, patients using sedative-hypnotics concurrently had 5.6 times the risk than patients without sedative-hypnotics (aHR, 5.6; 95% CI, 1.6-19.3). Our findings support Federal guideline-recommended dosing thresholds in opioid prescribing. Concurrent sedative-hypnotic use even at low opioid doses poses substantially greater risk of opioid overdose.

0525 UNMASKING PREDICTORS OF CONTINUOUS POSITIVE AIRWAY PRESSURE COMPLIANCE

Continuous positive airway pressure (CPAP) remains the treatment of choice for obstructive sleep apnea (OSA). Although it is an effective treatment, adherence is poor. The literature has failed to identify treatment variables that consistently predict CPAP adherence. We performed a retrospective analysis of patients with OSA started on CPAP in our clinic over the past 7 years. We compared those who were compliant after 30 days of CPAP use with those who did not demonstrate regular use, defined as CPAP use for ≥4 hours per night on 70% of nights. We assessed several clinical and demographic variables for their relationship with CPAP adherence including self-identified race, gender, sedative-hypnotic use during the diagnostic polysomnogram, mask type and brand. Differences between the groups were determined through the Chi-square test and Fisher’s Exact test. Two-thousand and four patients were included in the analysis (91% men, mean age 45.2 years ±10.8, mean AHI of 19.79 ± 15.1, mean BMI of 29.49 ± 8.7). At 30 days following the initiation of CPAP therapy, overall compliance was 66%. Patients treated with a full face mask (56.6%) were significantly more compliant (68.2%) compared to those using a nasal interface (63.5%; p-value of 0.032, OR 1.2). In regards to the different mask brands, there was no statistical significance between the six separate interfaces included in the database. Self-identified Asian patients (2%) were also more likely to be compliant (77.8%; p-value of 0.000, OR 2.9) compared to other categories of race. The use of a sedative hypnotic, eszopiclone or zolpidem, during the polysomnogram was not indicative of compliance (p-value of 0.887). Our study demonstrates a statistically superior CPAP compliance at 30 days amongst patients treated with full face masks. Although statistically significant, these findings are not felt to be clinically relevant. However, this contradicts previously published data that full face masks negatively affect CPAP adherence. Additional investigation is warranted to further identify treatment variables associated with improved CPAP compliance.

Prospective association between tobacco smoking and death by suicide: a competing risks hazard analysis in a large twin cohort with 35-year follow-up

The relationship between smoking and suicide remains controversial. A total of 16 282 twin pairs born before 1958 in Finland and alive in 1974 were queried with detailed health and smoking questionnaires in 1975 and 1981, with response rates of 89% and 84%. Smoking status and dose, marital, employment, and socio-economic status, and indicators of psychiatric and somatic illness were assessed at both time points. Emergent psychiatric and medical illness and vital status, including suicide determined by forensic autopsy, were evaluated over 35-year follow-up through government registries. The association between smoking and suicide was determined in competing risks hazard models. In twin pairs discordant for smoking and suicide, the prospective association between smoking and suicide was determined using a matched case-control design. Smokers had a higher cumulative suicide incidence than former or never smokers. Heavy smokers had significantly higher suicide risk [hazard ratio (HR) 3.47, 95% confidence interval (CI) 2.31-5.22] than light smokers (HR 2.30, 95% CI 1.61-3.23) (p = 0.017). Compared with never smokers, smokers, but not former smokers, had increased suicide risk (HR 2.56, 95% CI 1.43-4.59), adjusting for depressive symptoms, alcohol and sedative-hypnotic use, and excluding those who developed serious somatic or psychiatric illness. In twin pairs discordant for smoking and suicide, suicide was more likely in smokers [odds ratio (OR) 6.0, 95% CI 2.06-23.8]. Adults who smoked tobacco were more likely to die by suicide, with a large, dose-dependent effect. This effect remained after consideration of many known predictors of suicide and shared familial effects, consistent with the hypothesis that exposure to tobacco smoke increases the risk of suicide.

The relationship between mood disorder and insomnia depends on race in US veterans with epilepsy.

Few data exist on race, medical/psychiatric comorbidities, and insomnia symptoms in US veterans with epilepsy. Our aims were to examine 1) whether insomnia symptom prevalence was different between Black and White veterans and 2) whether predictors of insomnia symptoms varied by race. This retrospective, cross-sectional study included veterans evaluated in an epilepsy clinic over the course of 1.5years. Individuals completed standardized assessments for epilepsy and sleep complaints. Insomnia criteria were met by 1) report of difficulty with sleep initiation, maintenance, or premature awakenings accompanied by daytime impairment or 2) sedative-hypnotic use on most days of the month. Demographics, medical/psychiatric comorbidities, and medications were determined per electronic medical record review. Hierarchical multivariable logistic regression analyses were performed to determine if race, medical/mental health comorbidities, and the potential interaction of race with each comorbid condition were associated with insomnia. Our sample consisted of 165 veterans (32% Black). The unadjusted prevalence of insomnia was not different between Black and White veterans (42% vs 39%, p=0.68). In adjusted analyses, the association between mood disorder and insomnia varied by race. Depressed White veterans had over 11-times higher predicted odds of insomnia (OR 11.4, p<0.001) than non-depressed White veterans, while depressed Black veterans had 4-times higher predicted odds of insomnia (OR 4.1, p=0.06) than non-depressed Black veterans. Although mood disorder diagnosis was associated with insomnia for both racial groups, White veterans had a stronger association between mood disorder diagnosis and insomnia than Black veterans. The relationship between mood disorder diagnosis and insomnia was stronger for White than Black veterans with epilepsy. Future studies are needed to explore mental health symptoms and psychosocial determinants of insomnia with larger samples of minority individuals with epilepsy.

Use of Sedative-Hypnotic Drugs Among Older Adults

ABSTRACTThe purpose of this study was to reduce numbers of concurrently ordered sedative-hypnotic drugs for older adults in long-term (N = 220) and home-care (N = 357) settings. All active records were reviewed and numbers of sedative-hypnotics per patient were documented. Upon record review completion, educational sessions focused on dangers posed by use of multiple sedative-hypnotics were presented to nurses. One month posteducation, researchers reviewed the same records to evaluate changes. Matched pair t-tests suggested significant decreases in sedative-hypnotic use in long term, but not in the home care setting. Education in this area is critical within and across community settings.

The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment: Cognitive Behavioral Therapy for Insomnia.

Insomnia is a highly prevalent, often chronic condition, which is left untreated or not treated according to recommended guidelines in most cases. This results in high health and financial burdens to society. The cost of untreated insomnia and the prevailing reliance on sedative-hypnotic use as a first-line treatment are evaluated in this article. The cost-benefit potential of cognitive behavioral therapy for insomnia is also assessed.

Concomitant alcohol and sedative-hypnotic drug use among the elderly in Norway.

Background:Sedative-hypnotic drugs (i.e., tranquilizers and sleeping pills) are more often used among the elderly compared to other age groups. Concomitant use of alcohol and sedative-hypnotic drugs constitutes a particularly high risk factor for accidental injuries among the elderly. However, few studies have addressed the prevalence of concomitant alcohol and sedative-hypnotic drug use and knowledge about the characteristics of such use is meagre.Aim:To assess the prevalence of concomitant alcohol and sedative-hypnotic drug use among elderly people and to explore the characteristics of such concomitant use.Data and method:Data stemmed from cross-sectional population surveys in Norway, conducted in the period 2012–2015 (sub-sample 60–79 years: N = 1920).Results:Respondents reported frequencies of use of sedatives (tranquilizers), hypnotics (sleeping pills) and alcohol consumption in the preceding 12 months. Sedative-hypnotic drug use was reported by 25%, and 19% reported both such drug use and alcohol use in the past year. Concomitant use, suggesting simultaneous intake of alcohol and drugs, was reported by 6%.Conclusions:Concomitant use was more often reported by women, hazardous alcohol users, non-working respondents, and by those in the lower income groups and those living alone. Health personnel need to take into consideration the risks associated with concomitant use and to inform their patients accordingly.

Use of the EMPOWER brochure to deprescribe sedative-hypnotic drugs in older adults with mild cognitive impairment

BackgroundEvidence-based mailed educational brochures about the harms of sedative-hypnotic use lead to discontinuation of chronic benzodiazepine use in older adults. It remains unknown whether patients with mild cognitive impairment (MCI) are able to understand the information in the EMPOWER brochures, and whether they achieve similar rates of benzodiazepine discontinuation.MethodsPost-hoc analysis of the EMPOWER randomized, double-blind, wait-list controlled trial that assessed the effect of a direct-to-consumer educational intervention on benzodiazepine discontinuation. 303 community-dwelling chronic users of benzodiazepine medication aged 65–95 years were recruited from general community pharmacies in the original trial, 261 (86%) of which completed the trial extension phase. All participants of the control arm received the EMPOWER brochure during the trial extension. Normal cognition (n = 139) or MCI (n = 122) was determined during baseline cognitive testing using the Montreal Cognitive Assessment questionnaire. Changes in knowledge pre- and post-intervention were assessed with a knowledge questionnaire and changes in beliefs were calculated using the Beliefs about Medicines Questionnaire. Logistic regression was used to compare knowledge gained, change in beliefs and benzodiazepine cessation rates between participants with and without MCI.ResultsComplete discontinuation of benzodiazepines was achieved in 39 (32.0% [24.4,40.7]) participants with MCI and in 53 (38.1% [30.5,46.4]) with normal cognition (adjusted OR 0.79, 95% CI [0.45–1.38]). Compared to individuals with normal cognition, MCI had no effect on the acquisition of new knowledge, change in beliefs about benzodiazepines or elicitation of cognitive dissonance.ConclusionsThe EMPOWER brochure is effective for reducing benzodiazepines in community-dwelling older adults with mild cognitive impairment.Trial registrationOur ClinicalTrials.gov identifier is NCT01148186, June 21st 2010.

The pharmacokinetics and tissue distribution of coumaroylspinosin in rat: A novel flavone C-glycoside derived from Zizyphi Spinosi Semen.

Zizyphi Spinosi Semen (ZSS) has a long history of sedative-hypnotic use in China. As a novel flavone C-glycoside, coumaroylspinosin is a main flavonoid only found in ZSS. Up to now, its pharmacokinetic information and tissue distribution in vivo are not available yet. With a simple, rapid and sensitive HPLC-MS/MS method, the pharmacokinetics and tissue distribution of coumaroylspinosin were investigated in Sprague-Dawley (SD) rats after its intravenous administration. Puerarin was used as the internal standard (IS). The samples were extracted by a simple protein precipitation method with methanol. The MS analysis was performed with multiple reaction monitoring (MRM), and the transitions were set at m/z 753.3→427.0 for coumaroylspinosin and m/z 415.3→295.3 for IS, respectively. The method was successfully applied for investigating the pharmacokinetics and tissue distribution of coumaroylspinosin in Sprague Dawley (SD) rats after tail vein injection with 4.0mg/kg of the flavonoid. The calibration curves covered over the range of 0.02-10μg/mL in plasma and various tissues samples with good linearity(r≥0.9956). The lower limit of quantification (LLOQ) in all samples was less than 20ng/mL. The intra- and inter-day precisions were below 15% and accuracy was from -3.78% to 4.68%. No significant matrix effect was observed, and the average extraction recovery was acceptable. Coumaroylspinosin could be cleared quickly from the rat plasma with the half-life (t1/2) of 1.86±0.15h. It was distribute widely in vivo, and the main tissue depots of coumaroylspinosin in rats were found to be intestine, muscle and lung. With the method, the pharmacokinetic parameters and tissue distribution of coumaroylspinosin in SD rats were investigated for the first time. The results demonstrated that coumaroylspinosin was distributed widely and rapidly in various rat tissues after intravenous administration.

Initial treatment dropout in patients with substance use disorders attending a tertiary care de-addiction centre in north India.

Background & objectives:Dropout from substance use disorders treatment is associated with poor outcomes. Although many factors have been associated with an early dropout of patients, the reasons for dropping out of treatment prematurely remain poorly understood particularly in the Indian context. This study was aimed to study socio-demographic and clinical variables predicting initial dropout of patients attending a tertiary care de-addiction treatment centre in north India.Methods:Information was extracted from the records of consecutive newly registered patients from January 2011 to December 2014. The patients who did not come for follow up within 30 days of the first contact were defined as initial dropouts.Results:Data of 7991 patients could be retrieved. Majority of the sample consisted of male, married and employed individuals. Of them, 4907 patients (61.3%) were considered initial dropouts. Multivariate analysis revealed that after controlling for other factors, greater age, being employed, lower educational status, lesser duration of substance use, use of alcohol, opiate, tobacco, cannabis or sedative-hypnotic use but the absence of multi-substance use predicted initial drop out.Interpretation & conclusions:This study identified some socio-demographic and clinical variables which might predict treatment attrition in substance use disorders. Clinician's awareness towards these factors and tailor-made intervention might improve initial treatment retention. Future research could be directed to find the validity of this assumption.

Sedative-Hypnotic Use Among Older Adults Participating in Anxiety Research

Older adults are prescribed sedative-hypnotic medications at higher rates than younger adults. These are not recommended for older adults due to risk of sedation, cognitive impairment, and falls. Severe generalized anxiety disorder (GAD) is a possibly appropriate use of these medications in older people, but little is available on use of sedative-hypnotic medications among older adults with GAD. This study examined the frequency and predictors of sedative-hypnotic medication use among older adults screening positive for anxiety. 25.88% ( n = 125) of participants reported taking sedative-hypnotics over the past 3 months; 16.36% ( n = 79) reported taking benzodiazepines, and 12.22% ( n = 59) reported taking hypnotic sleep medications. Depressive symptoms were more strongly associated with sedative-hypnotic use than insomnia or worry. Major depressive disorder and posttraumatic stress disorder, but not GAD, predicted sedative-hypnotic use. Other medications and treatments are more appropriate and efficacious for depression, anxiety, and insomnia in this population.

Understanding Risk Factors for Opioid Overdose in Clinical Populations to Inform Treatment and Policy.

Overdoses involving opioid analgesics represent a significant public health problem in the United States. We reviewed the literature on risk factors for overdose, with a focus on studies that examine clinical populations of patients receiving opioids for pain and potential risk factors for overdose in these populations. A structured review resulted in 15 articles published between 2007 and 2015 that examined risk factors for fatal and nonfatal overdose in patients receiving opioid analgesics. Opioid dosage was the factor most consistently analyzed and also associated with increased risk of overdose. Other risk factors include concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and the presence of substance use and other mental health disorder comorbidities. Future research is needed to better characterize populations taking opioids for pain to help clarify discrepancies between existing studies and identify previously unexplored risk factors for overdose. Given that policy and clinical practice have shifted as a result of prior studies reviewed here, further efforts in understanding patient groups and opioid-related prescribing practices associated with overdose risk have great potential to impact policy and practice in the treatment of pain while improving the safety around opioid prescribing.

'Sometimes, it's easier to write the prescription': physician and patient accounts of the reluctant medicalisation of sleeplessness.

The medicalisation of sleep is a rich and growing area of sociological interest. Previous research suggests that medicalisation is occurring within the context of physician office visits, but the inner workings remain unclear. This study is the first to provide perspectives on the office visit interaction from both sleepless patients (n=27) and the physicians (n=8) who treat them. Analyses of semi-structured qualitative interviews reveal that sleep-related conversations are typically patient-initiated in routine office visits. Physicians and patients conceptualised insomnia as a symptom of another issue (depression), an everyday problem of living (stress) or the result of a natural life process (aging). Lack of sleep was not necessarily linked to daytime impairment. Even though sleep aids were routinely requested and prescribed, patients and physicians consistently expressed attitudes of reluctance toward the use of sedative hypnotics. I call this a case of 'reluctant medicalisation' and highlight the liminal space between pathology and normalcy inhabited by patients and physicians. I also build on recent work acknowledging the dynamics between macro and micro levels of medicalisation and illustrate the influence of multilevel 'engines' (consumerism, biotechnology, managed care and physicians) in patients' and physicians' accounts. A virtual abstract of this paper can be viewed at: https://youtu.be/7uLHOJPHF0I.

A survey of primary care patients' readiness to engage in the de-adoption practices recommended by Choosing Wisely Canada.

BackgroundStrategies such as Choosing Wisely have been established to identify the overuse of interventions considered as low-value. Reduction of low-value practices will require patients to understand why certain interventions are no longer recommended. The objective of this study was to determine whether older adults accept the rationale for and perceive themselves ready to de-adopt annual electrocardiogram testing, imaging for low back pain, the use of antibiotics for sinusitis, the use of sedative-hypnotics for insomnia, and the use of antipsychotics to treat behavioural symptoms of dementia.MethodsA self-administered iPad survey was distributed to consecutive patients aged 50 years and older, presenting to three primary care outpatient practices in Ontario, Canada. Data from patients who were able and willing to complete the survey while waiting to see their physician were included. The survey queried knowledge, attitudes and behaviours around the targeted low-value interventions, before and after exposure to a Choosing Wisely Canada patient educational brochure on one of these five topics. A subset of patients agreed to participate in a semi-structured interview after their clinic visit.ResultsThree-hundred and forty-four patients (mean age 63, range 50–88, 59 % female) read the materials and completed the survey. Forty-eight percent (95 % CI 43–53 %) intended to discuss the information with a healthcare provider. Forty-five percent (95 % CI 40–51 %) expressed a desire to change current low-value practices. Approximately two-thirds of those who indicated they would not change future behaviours explained that it was because they were already espousing the Choosing Wisely values. After reading the Choosing Wisely brochures, knowledge improved independent of age, sex and education in 48 % (95 % CI 38–57 %) of participants about electrocardiogram testing, in 74 % (95 % CI 65–82 %) about use of antipsychotics, in 66 % (95 % CI 52–78 %) about use of antibiotics for sinusitis, in 60 % (95 % CI 46–72 %) about imaging for low back pain, and in 40 % (95 % CI 26–55 %) about sedative-hypnotic use in the elderly.ConclusionsThe majority of primary care patients seem ready to de-adopt low-value practices. Provision of education in clinic waiting rooms can help improve knowledge around unnecessary care.

Severity of self-reported insomnia in adults with epilepsy is related to comorbid medical disorders and depressive symptoms.

Few studies have systematically investigated insomnia in adults with epilepsy. We performed a prospective cross-sectional investigation of the prevalence, severity, and comorbidities of insomnia in 90 adults with epilepsy using a battery of self-reported instruments and polysomnography. We quantified insomnia severity using the Insomnia Severity Index (ISI). Fifty-nine of 90 (65.5%) adults with epilepsy reported insomnia (ISI≥8), moderate or severe (ISI≥15) in 28.9%. Good agreement between standard clinical diagnostic criteria and ISI was found for patients with ISI scores <8 and ≥15. Scores on the modified Beck Depression Inventory (mBDI) (r=0.25, p=0.021), the original BDI (r=0.32, p=0.002), and self-reported total sleep duration (TSD) (r=-0.3, p=0.006) were significantly related to ISI score. A multiple regression model found that decreased TSD (ß=-0.93, p=0.007), head trauma (ß=4.37, p=0.003), sedative-hypnotic use (ß=4.86, p=0.002), AED polytherapy (ß=3.52, p=0.005), and asthma/COPD (ß=3.75, p=0.014) were predictors of a higher ISI score. For 63 patients with focal epilepsy, an increased mBDI (ß=0.24, p=0.015), decreased TSD (ß=-1.11, p=0.008), asthma/COPD (ß=4.19, p=0.02), and epilepsy surgery (ß=5.33, p=0.006) were significant predictors of an increased ISI score. Patients with temporal lobe epilepsy (TLE) showed a trend for greater severity compared with those with extra-TLE (ß=-2.92, p=0.054). Our findings indicate that severity of insomnia in adults with epilepsy is more likely to be associated with comorbid medical and depressive symptoms and less likely to be directly related to epilepsy. Good agreement between standard clinical diagnostic criteria for insomnia and the ISI for subjects without insomnia symptoms and for those with moderate-to-severe symptoms supports the use of this instrument in epilepsy research.

Sedative hypnotic use among veterans with a newly reported mental health disorder.

This study compared sedative hypnotic use by type of mental health diagnosis and determined factors associated with use among older veterans (65+ years) with a newly reported mental health disorder. This study used data from veterans who received primary care services at VA Pittsburgh Healthcare System (VAPHS) from January 1, 2007 to December 31, 2011 (n = 879). Sedative hypnotics were commonly used in older veterans within 12-months following a newly reported mental health disorder (19.9%), particularly amongst those with insomnia (41.7%). The number of newly reported mental health disorders was a significant factor associated with sedative hypnotic use, with the odds of use increasing by more than 200% in older adults with two newly reported disorders compared to those with one newly reported mental health disorder. Continued efforts are needed to improve provider and patient awareness of the risks associated with sedative hypnotic use in older adults, as well as to increase access to and receipt of non-pharmacological mental health treatments for this vulnerable population.

Management of late-life insomnia

IntroductionInsomnia is the most frequent sleep disorder in late life. Forty-two percent of elderly people in the United States often complain about difficulties to get or maintain sleep, or awakening too early. Insomnia is frequent in old people greatly due to frequency of concomitant medical illnesses and polypharmacy, rather than because of age.ObjectivesThe objective of our research was to revise the current state of knowledge about management of insomnia in people above 65 years of age.MethodologyFor that, a bibliographical search through PubMed.gov has been made. From the obtained results, the 14 which best suited for our goals were selected, 10 of them dealing with people above 65 years and the rest with people above 75 or 80 years of age.ResultsBased on the literature reviewed, the current options of management of late-life insomnia are based on behavioral or pharmacological therapy. The combination of behavioral therapies shows results and is currently considered as an option, especially given the possibility of medicine interaction and the secondary effects hypnotic and sedative medicines might produce. There is a paucity of long-term safety and efficacy data for the use of non-benzodiazepine sedative-hypnotics. There are no criteria for the use of antidepressant sedatives in elderly people without diagnosed depression, although they are still used in practice.ConclusionPossibility of using behavioral therapy as first option. In case of polymedicated or multi-pathological patients, pay special attention when starting a pharmacological treatment, choose the most suitable one and supervise it closely.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Psychotropic use and associated neuropsychiatric symptoms among patients with dementia in the USA.

To determine the national prevalence of psychotropic use and association with neuropsychiatric symptoms among patients with dementia. Participants diagnosed with dementia (n = 414) in the Aging, Demographics, and Memory Study, a nationally representative survey of US adults >70 years old. Diagnosis was based on in-person clinical assessment and informant interview. Information collected included demographics, place of residence, 10-item Neuropsychiatric Inventory (NPI), and prescribed medications (antipsychotic, sedative-hypnotic, antidepressant, mood stabilizer). Of 414 participants with dementia, 41.4% were prescribed a psychotropic medication, including 84.0% of nursing home residents and 28.6% of community-dwellers. Of participants, 23.5% were prescribed an antidepressant. Compared with the total NPI score of those on no medication (4.5), those on antipsychotics and those on sedative-hypnotics had much higher scores (respectively: 12.6, p < 0.001; 11.8, p = 0.03), although those antidepressants did not (6.9, p = 0.15). A larger proportion of patients on antipsychotics exhibited psychosis and agitation compared with those on no medication, while those on antidepressants exhibited more depressive symptoms. In multivariable logistic regression that included dementia severity and nursing home residence, nursing home residence was the characteristic most strongly associated with psychotropic use (odds ratio ranging from 8.96 [p < 0.001] for antipsychotics to 15.59 [p < 0.001] for sedative-hypnotics). More intense psychotic symptoms and agitation were associated with antipsychotic use; more intense anxiety and agitation were associated with sedative-hypnotic use. More intense depression and apathy were not associated with antidepressant use. In this nationally representative sample, 41.4% of patients were taking psychotropic medication. While associated with neuropsychiatric symptoms, nursing home residence was most strongly tied to use. Copyright © 2016 John Wiley & Sons, Ltd.

Trends in prescribing of sedative-hypnotic medications in the USA: 1993-2010.

Non-benzodiazepine receptor agonists (nBZRAs) were developed as an alternative to benzodiazepines (BZDs) to treat insomnia. Little is known about how the introduction of nBZRAs influenced trends in BZD prescribing. We examined BZD and nBZRA prescribing trends from 1993 to 2010. We used the National Ambulatory Medical Care Survey to examine 516,118 patient visits between 1993 and 2010. We categorized visits as BZD, nBZRA, or BZD + nBZRA visits based on medications prescribed in each visit and applied linear probability regression models to assess trends in visits. Increases were observed in proportions of visits that were BZD (2.6% in 1993 to 4.4% in 2010, p < 0.001) and nBZRA (0% to 1.4%, p < 0.001). Increases in BZD visits were primarily after 2002, with prescribing in the preceding years remaining relatively stable. We also found increases in BZD + nBZRA visits (0% to 0.4%, p < 0.001). Among patients with sleep disorders, there was an increase in nBZRA visits (2.3% to 13.7%, p < 0.001), and decline in BZD visits (23.5% to 10.8%, p = 0.015). Just under a third (30.8%) of any sedative-hypnotic visits were for adults aged 65+ years, among whom increases in BZD, nBZRA, and BZD + nBZRA visits were observed across the study period. There were increases in prescribing of nBZRAs between 1993 and 2010. Increases in prescribing of BZDs were also observed, especially after 2002. The introduction of nBZRAs likely resulted in declines in BZD prescribing among those with a sleep disorder, but not other groups. Delivery of behavioral treatments should be encouraged to avert adverse outcomes associated with sedative-hypnotic use. Copyright © 2015 John Wiley & Sons, Ltd.

Licit and illicit substance use among people who inject drugs and the association with subsequent suicidal attempt.

To estimate associations between recent licit and illicit substance use and subsequent suicide attempt among people who inject drugs (PWID). Secondary analysis of longitudinal data from a prospective cohort study of PWID followed bi-annually between 2004 and 2011. Montréal, Canada. Seven hundred and ninety-seven PWID who reported injection drug use in the previous 6 months, contributing to a total of 4460 study visits. The median number of visits per participant was five (interquartile range: 3-8). An interviewer-administered questionnaire eliciting information on socio-demographic factors, detailed information on substance use patterns and related behaviours, mental health markers and suicide attempt. The primary exposure variables examined were past-month use of alcohol [heavy (≥ 60 drinks); moderate (one to 59 drinks); none], sedative-hypnotics, cannabis, cocaine, amphetamine and opioids [regular (≥ 4 days); occasional (1-3 days); none]. The outcome was a binary measure of suicide attempt assessed in reference to the previous 6 months. In multivariate analyses, a positive association was found among licit substances between heavy alcohol consumption [adjusted odds ratio (AOR) = 2.05; 95% confidence interval (CI) = 1.12-3.75], regular use of sedative-hypnotics (AOR = 1.89; 95% CI = 1.21-2.95) and subsequent attempted suicide. Among illicit substances, occasional use of cannabis (AOR = 1.84; 95% CI = 1.09-3.13) had a positive association with subsequent suicide attempt. No statistically significant association was found for the remaining substances. Among people who inject drugs, use of alcohol, sedative-hypnotics and cannabis, but not cocaine, amphetamine or opioids, appears to be associated with an increased likelihood of later attempted suicide.