Sedative-hypnotic Prescriptions Research Articles

Clinical pharmacist intervention to ensure safe stimulant prescribing practices at a Veterans Affairs facility.

The Psychotropic Drug Safety Initiative (PDSI) is a national Veterans Affairs program that recommends obtaining cardiovascular vital signs semiannually and urine toxicology screening annually for veterans prescribed stimulants. The PDSI also recommends a risk review of concurrent central nervous system (CNS) depressants to ensure the benefits of coadministration with stimulants outweigh the risks. This project's purpose was to evaluate the occurrence of coprescriptions for CNS depressants and stimulants and encourage compliance with the PDSI recommendations to increase safe and appropriate management of veterans prescribed the combination. This study aimed to evaluate the occurrence of coprescriptions for CNS depressants and stimulants, evaluate compliance with stimulant monitoring recommendations, and measure the proportion of pharmacist recommendations implemented by the prescriber. This quality improvement project identified veterans with an outpatient prescription for a stimulant and any coprescription(s) for benzodiazepines, sedative-hypnotics, and/or opioids. A pharmacy intervention note was generated to request a risk review, provide recommendations for de-escalation, and notify the stimulant prescriber of overdue monitoring parameters. Impact was measured 60 days after intervention. Descriptive statistics and a McNemar test were used to compare preintervention and postintervention data. From the 61 patients included, there were 67 unique prescriptions for benzodiazepines (49.3%), sedative-hypnotics (34.3%), and opioids (16.4%) in combination with a stimulant. Pharmacist intervention resulted in de-escalation of coprescribing for 9 patients (16.1%) and was associated with statistically significant improvement in compliance to stimulant monitoring recommendations. Clinical pharmacists can assist in ensuring safe and appropriate monitoring and management of veterans prescribed stimulants.

Management of sleep disorder by preceptors in a family medicine residency program in Calgary, Alberta: a mixed-methods study.

Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems. Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis. Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management. Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.

Reducing Sedative-Hypnotics Among Hospitalized Patients: a Multi-centered Study.

Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. We aimed to examine whether a sedative-hypnotic reduction quality improvement bundle decreases the rate of sedative-hypnotic use among hospitalized patients, who were previously naïve to sedative-hypnotics. This interrupted time series study occurred between May 2016 and January 2019. Control data for 1 year prior to implementation and intervention data for at least 16 months were collected. The study occurred on 7 inpatient wards (general medicine, cardiology, nephrology, general surgery, and cardiovascular surgery wards) across 5 teaching hospitals in Toronto, Canada. Participating wards implemented a sedative-hypnotic reduction bundle (i.e., order set changes, audit-feedback, pharmacist-enabled medication reviews, sleep hygiene, daily sleep huddles, and staff/patient/family education) aimed to reduce in-hospital sedative-hypnotic initiation for insomnia in patients who were previously naïve to sedative-hypnotics. Each inpatient ward adapted the bundle prior to sustaining the intervention for a minimum of 16 months. The primary outcome measure was the proportion of sedative-hypnotic-naïve inpatients newly prescribed a sedative-hypnotic for sleep in hospital. Secondary measures include prescribing rates of other sedating medications, fall rates, length of stay, and mortality. We included 8,970 patient discharges in the control period and 10,120 in the intervention period. Adjusted sedative-hypnotic prescriptions among naïve patients decreased from 15.48% (95% CI: 6.09-19.42) to 9.08% (p<0.001) (adjusted OR 0.814; 95% CI: 0.667-0.993, p=0.042). Unchanged secondary outcomes included mortality (adjusted OR 1.089; 95% CI: 0.786-1.508, p=0.608), falls (adjusted rate ratio 0.819; 95% CI: 0.625-1.073, p=0.148), or other sedating drug prescriptions (adjusted OR 1.046; 95% CI: 0.873-1.252, p=0.627). A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.

Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016.

Previous work has demonstrated significant declines in the provision of outpatient psychotherapy by U.S. psychiatrists. The objective of this study was to characterize patterns and trends of psychotherapy by U.S. psychiatrists from 1996 to 2016. A retrospective, nationally representative analysis of psychiatrist visits from 21 waves of the U.S. National Ambulatory Medical Care Survey between 1996 and 2016 (N=29,673) was conducted to assess rates of outpatient psychotherapy provision by U.S. psychiatrists. Provision was modeled as risk differences and adjusted by clinical, sociodemographic, geographic, and financial characteristics. Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016. Declines were most marked among patients diagnosed with social phobia (29% to 8%), dysthymic disorder (65% to 30%), and personality disorders (68% to 17%). For patients diagnosed with schizophrenia, psychotherapy provision remained stable (10%-12%). In the 2010-2016 period, about half of psychiatrists (53%) no longer provided psychotherapy at all. Antidepressant, antipsychotic, and sedative-hypnotic prescriptions were negatively associated with psychotherapy provision. During the study period, sociodemographic disparities grew, with older, White patients residing in metropolitan areas in the Northeast or West increasingly becoming the most likely to receive psychotherapy. Self-pay predicted access to solo-practice psychiatrists, who saw fewer patients but more frequently, and were more likely to provide psychotherapy. Previously reported declines in psychiatrist provision of psychotherapy continued through 2016, affecting nearly all clinical categories. In the 2010s, about half of psychiatrists practiced no psychotherapy at all, creating new challenges to the integration of neurobiological and psychosocial elements of clinical care.

Secondary effects of an opioid-focused academic detailing program on non-opioid controlled substance prescribing in primary care

Background: Educational outreach programs that focus on safe opioid prescribing and awareness of state prescription monitoring programs may modify clinicians’ prescribing behavior. The objective of this study was to evaluate the secondary effects of an opioid-focused academic detailing (AD) program on non-opioid controlled substance prescribing in primary care. Methods: A quasi-experimental pre-post study of primary care clinicians exposed and unexposed to the AD program was conducted using data from the Illinois Prescription Monitoring Program from December 2017 to February 2019. Outcomes were mean monthly prescriptions for benzodiazepines (BZD), non-BZD sedative-hypnotics, and carisoprodol, per clinician. A difference-in-differences (DID) approach utilizing repeated-measures mixed-effects linear regression models was used to compare changes in outcomes six-months before and after the program. Results: Mean monthly BZD prescriptions declined in both groups of clinicians (AD-exposed n = 151; controls n = 399) after implementation of the AD program. Although the mean monthly number of BZD prescriptions decreased in both groups after the AD program, BZD prescribing in the AD-exposed group declined at a slower rate following the AD program (DID = 0.73; 95% CI: 0.14, 1.31). The AD-exposed group had a 0.06 (95% CI: −0.11, −0.01) lower rate of mean monthly carisoprodol prescriptions compared to the control group following the AD program. There was no change in the rate of mean monthly non-BZD sedative-hypnotic prescriptions between the two groups. Conclusions: The higher relative rate of BZD prescribing in the AD-exposed group compared to the control group following the AD program may be reflective of an unintended consequence of opioid-focused AD programs as clinicians learn to be cautious about opioid prescribing. Our findings may suggest the need for incorporation of targeted education on appropriate BZD prescribing into opioid-focused AD programs as a featured component. These findings warrant further consideration and investigation before large-scale implementation of opioid-focused educational outreach programs.

The 5-year pre- and post-hospitalization treated prevalence of mental disorders and psychotropic medication use in critically ill patients: a Canadian population-based study.

The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes. Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations. The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92-0.97, p < 0.0001; 5-year APR 0.99, 95% CI 0.98-1.00, p = 0.1), but higher following discharge (1-year APR 1.08, 95% CI 1.05-1.11, p < 0.0001, 5-year APR 1.03, 95% CI 1.01-1.05, p < 0.0001). A high proportion of ICU patients received antidepressant, anxiolytic and sedative-hypnotic prescriptions before and after their hospitalization. In multivariable analyses, ICU exposure was associated with an increase in mood, anxiety and psychotic disorders, and sedative-hypnotics use (p < 0.0001 for all Time×Group interactions). During the 5years after admission to ICU, there is a significant increase in treated prevalence of mental disorders and psychotropic medication use compared to the 5years prior to ICU and compared to general population and hospital cohorts. Prevention and intervention programs that identify and treat mental disorders among survivors of critical illness warrant further study.

Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veteran VA Users Nationwide With Traumatic Brain Injury, 2012-2020

Many post-9/11 Veterans have received Department of Veterans Affairs (VA) healthcare for traumatic brain injury (TBI). Pain conditions are prevalent among these patients and are often managed with opioid analgesics. Opioids may impose unique risks to Veterans with a history of TBI, especially when combined with other psychotropic medications. We examined receipt of opioid and sedative-hypnotic prescriptions among post-9/11 Veterans with TBI who received VA care nationally between 2012 and 2020. Nationwide VA outpatient care. Veterans with, versus without, clinician-confirmed TBI based on the VA's Comprehensive TBI Evaluation (CTBIE) were followed up for subsequent years in which they received VA care. A historical cohort study. Proportions of Veterans who received opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were compared by CTBIE outcome (TBI yes/no) and by year; overlaps between medication classes, long-term opioid therapy, and high-dose opioid therapy were also examined. Among those with confirmed TBI, logistic regression was used to examine associations between veteran characteristics and likelihood of these potentially high-risk opioid use outcomes. Among 69 752 Veterans with clinician-confirmed TBI, 26.9% subsequently received opioids. The prevalence receiving opioids each year increased from 2012 (16.7%) to 2014 (17.7%), and then decreased each of the following years through 2020 (5.8%). Among Veterans with TBI who received opioids, large proportions also received benzodiazepine (30.1%) and nonbenzodiazepine (36.0%) sedative-hypnotic prescriptions; these proportions also decreased in recent years. In both bivariable and multivariable regression models, Veterans' demographic, TBI, and clinical characteristics were associated with likelihood of potentially high-risk opioid use. VA opioid prescribing to Veterans with TBI has decreased in recent years but remains an important source of risk, particularly when considering coprescriptions of sedative-hypnotic medication. Understanding patterns of psychotropic prescription use among Veterans with TBI can highlight important healthcare and rehabilitation needs in this large patient cohort.

Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury.

Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. Oregon VA and non-VA outpatient care. Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. Historical cohort study. Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

Implementation of a digital cognitive behavioral therapy for insomnia pathway in primary care

BackgroundInsomnia is a prevalent and debilitating disorder commonly managed by family physicians. Insomnia guidelines recommend cognitive behavioral therapy for insomnia (CBTi) as the ‘first-line’ treatment. However, family physicians report limited time, knowledge, access, support, and referral options to manage patients with CBTi. Consequently, many patients with insomnia are prescribed potentially harmful and addictive sedative-hypnotic medicines (e.g. benzodiazepines). Family physicians require an insomnia management pathway that is specifically tailored to the guideline-recommendations, time demands, and capacity of family practice.MethodsThis mixed-methods implementation trial will test the feasibility, acceptability and effectiveness of a comprehensive digital insomnia management pathway in family practice. This novel pathway includes digital recruitment of family physicians, automatic identification of patients whose electronic medical records contain recent sedative-hypnotic prescriptions using a software management pathway and real-time notifications prompting physicians to refer patients to a well-established digital CBTi program. At least 10 family physicians and 375 patients with insomnia will be recruited. Physicians will be provided with an eBook to guide gradual sedative-hypnotic withdrawal. Feasibility and acceptability will be assessed from the perspective of patients and physicians. Effectiveness will be determined by co-primary outcomes: cessation of sedative-hypnotic use, and improvement in self-reported insomnia symptoms from baseline to 12-month follow-up. Analysis of trends in costs, cost-effectiveness and cost-utility analyses will be conducted from a societal perspective.Results and discussionThis implementation trial will pave the way for future scaling-up of this insomnia management pathway to improve access to CBTi and reduce reliance on sedative-hypnotic medicines in family practice.Trial Registration: This trial was prospectively registered on the Australian and New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12619001539123).

New and persistent controlled substance use among patients undergoing mastectomy and reconstructive surgery.

Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications. Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors. We evaluated 23,025 opioid-naïve women and 25,046 sedative-hypnotic-naïve women. We found that 17,174 opioid-naïve women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40-2.24)] and age 50-64 [1.60 (1.27-2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40-3.90)]; southern residence [1.42 (1.22-1.64)]; breast cancer diagnosis [2.24 (1.28-3.91)]; and chemotherapy [2.17 (1.94-2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51-3.43)]. Comparable findings were seen regarding new persistent opioid use. Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient's risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

0547 Insomnia in Veterans with COPD: Prevalence, Correlates, and Health Care Utilization

Abstract Introduction Veterans with COPD are a vulnerable group for developing insomnia. The objectives of this study were to examine the prevalence and correlates of insomnia and its impact on health care utilization in a national sample of Veterans with COPD. Methods National data from electronic medical records of Veterans who utilized the Veterans Health Administration between FY2011 and FY2017 was accessed from the Veterans Affair Corporate Data Warehouse. COPD was based on International Classification of Diseases diagnostic codes (ICD-9/10). Insomnia was defined by ICD-9/10 codes or sedative-hypnotic prescription of &amp;gt;30 doses in a given fiscal year. ICD-9/10 codes for other conditions were documented. Outpatient and inpatient health care service utilization included number of physician encounters and emergency room visits and hospitalizations with a primary diagnostic code for COPD or COPD exacerbation. Bivariate comparisons between veterans with COPD and insomnia and COPD only were made for sociodemographic, comorbidities, and health care utilization variables using t-tests and Chi-square tests, as appropriate. Results A total of 1,542,642 Veterans with COPD were identified during the 6-year period. Of those with COPD, 575,539 (37.3%) were identified as having insomnia. Veterans with COPD and comorbid insomnia were younger (64 years vs. 69 years) and more likely to be female (6.3% vs. 3.7%), Black (14.0% vs. 11.0%), be a current smoker (46.1% vs. 35.5%), and have comorbidities including obstructive sleep apnea, diabetes, asthma, stroke, depression, or posttraumatic stress disorder compared to those without insomnia (all p’s &amp;lt;0.001). Compared to Veterans with COPD only, those with comorbid insomnia had a greater number of COPD-related outpatient (6.9 vs. 10.5) and emergency room (1.1 vs. 1.2) visits and hospitalizations (1.9 vs. 2.3) (p’s &amp;lt;0.001). Conclusion Insomnia is highly prevalent in Veterans with COPD and is associated with greater COPD-related health care utilization. Future research is needed to determine if targeted treatment for insomnia can improve COPD outcomes. Support This study was funded by the VA Competitive Career Development Fund.

Opioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm?

Journal of NeurotraumaVol. 37, No. 1 Short CommunicationOpioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm?Rachel Sayko Adams, John D. Corrigan, and Kristen Dams-O'ConnorRachel Sayko AdamsInstitute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado.Search for more papers by this author, John D. CorriganDepartment of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio.Search for more papers by this author, and Kristen Dams-O'ConnorAddress correspondence to: Kristen Dams-O'Connor, PhD, Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1163, New York, NY 10029 E-mail Address: Kristen.Dams-O'Connor@mountsinai.orgDepartment of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York.Search for more papers by this authorPublished Online:11 Dec 2019https://doi.org/10.1089/neu.2019.6451AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byCaring again: Support for parent caregivers of wounded, ill, and/or injured adult children veteransNeuroRehabilitation, Vol. 52, No. 1Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems studyJournal of Clinical Sleep Medicine, Vol. 19, No. 1Association between traumatic brain injury and suicidality using a mediation approach and MarketScan5 December 2022 | Injury Prevention, Vol. 26Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patientsJournal of Clinical Anesthesia, Vol. 79Peer Support at the Intersection of Disability and Opioid (Mis)Use: Key Stakeholders Provide Essential Considerations5 August 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 15Preinjury Health Status of Adults With Traumatic Brain Injury: A Preliminary Matched Case-Control Study15 June 2021 | Journal of Head Trauma Rehabilitation, Vol. 37, No. 3Repeated blast mild traumatic brain injury and oxycodone self‐administration produce interactive effects on neuroimaging outcomes18 January 2022 | Addiction Biology, Vol. 27, No. 2Impact of opioid use disorder on resource utilization and readmissions after operative traumaSurgery, Vol. 171, No. 2Pregnancy, Fetal, and Neonatal Outcomes Among Women With Traumatic Brain Injury14 October 2022 | Journal of Head Trauma Rehabilitation, Vol. Publish Ahead of PrintExamining differences in prescription opioid use behaviors among U.S. adults with and without disabilitiesPreventive Medicine, Vol. 153Reported History of Traumatic Brain Injury Among Suicide Decedents: National Violent Death Reporting System, 2003–2017American Journal of Preventive Medicine, Vol. 61, No. 4When triggers become tigers: taming the autonomic nervous system via sensory support system modulation7 September 2021 | Journal of Social Work Practice in the Addictions, Vol. 37Risk Factors Associated With the Prescription of Opioids Among Service Members Following a First Mild Traumatic Brain InjuryJournal of Head Trauma Rehabilitation, Vol. 36, No. 5Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veteran VA Users Nationwide With Traumatic Brain Injury, 2012-2020Journal of Head Trauma Rehabilitation, Vol. 36, No. 5Scoping Review of Opioid Use After Traumatic Brain InjuryJournal of Head Trauma Rehabilitation, Vol. 36, No. 5Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain InjuryJournal of Head Trauma Rehabilitation, Vol. 36, No. 5Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among AdultsJournal of Head Trauma Rehabilitation, Vol. 36, No. 5Traumatic Brain Injury and Opioid Use: Additional Evidence Supporting the “Perfect Storm” of Cascading VulnerabilitiesJournal of Head Trauma Rehabilitation, Vol. 36, No. 5Association between Lifetime History of Traumatic Brain Injury, Prescription Opioid Use, and Persistent Pain: A Nationally Representative Study Raj G. Kumar, Katherine A. Ornstein, John D. Corrigan, Rachel Sayko Adams, and Kristen Dams-O'Connor26 July 2021 | Journal of Neurotrauma, Vol. 38, No. 16Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness17 February 2021 | Frontiers in Pharmacology, Vol. 12 Volume 37Issue 1Jan 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Rachel Sayko Adams, John D. Corrigan, and Kristen Dams-O'Connor.Opioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm?.Journal of Neurotrauma.Jan 2020.211-216.http://doi.org/10.1089/neu.2019.6451Published in Volume: 37 Issue 1: December 11, 2019Online Ahead of Print:August 16, 2019Online Ahead of Editing: July 23, 2019PDF download

Predictors of Long-Term and High-Dose Use of Zolpidem in Veterans.

Prescriptions for sedative hypnotics are routinely initiated and renewed to treat insomnia, despite evidence supporting nonpharmacologic treatments as comparable and more favorable over time. We used national Veterans Health Administration data to assess patient characteristics associated with high-dose and long-term zolpidem use. The study included outpatients with new zolpidem prescriptions (January 1, 2013, to June 3, 2014). We defined high-dose use as use of doses above those recommended in the 2013 FDA safety warning (> 5 mg for women, > 10 mg for men) and defined long-term use as at least 180 days of continued supply. We fit separate logistic regression models by sex to evaluate how patient factors, adjusting for facilities, predicted high-dose and long-term use. Of 139,525 new zolpidem users, < 1% of men and 41% of women used high doses within 180 days of initiation, and 20% continued to use zolpidem long-term. Prior-year use of other sleep medications was associated with both high-dose and long-term use. Substance abuse/dependence was associated with high-dose use in women (odds ratio = 1.20, P < .001). Although long-term use was less likely in those over the age of 85 years, about 1 in 5 users aged 65 to 85 continued long-term. In both sexes, individuals of Hispanic ethnicity and nonwhite races were less likely to use long-term, whereas those with ICD-9-CM-defined psychiatric and sleep disorder diagnoses were more likely to use long-term. Zolpidem use at a higher-than-recommended dose was common in women who were new zolpidem users. In both sexes, 1 in 5 users continued to use zolpidem for at least 180 days. Efforts to improve access to effective nonpharmacologic treatment alternatives may benefit from attention to subpopulations with higher risk of high-dose and long-term use.

Trends in prescriptions for sedative-hypnotics among Korean adults: a nationwide prescription database study for 2011-2015.

This study investigated prescriptions for sedative-hypnotics via data obtained from the Health Insurance Review and Assessment (HIRA) service. Data on sedative-hypnotic prescriptions from the HIRA service of the Republic of Korea were analyzed from 2011 to 2015. We included prescriptions for subjects > 18years of age from hospitals and community healthcare centers. In addition, subgroup analyses with a subsample restricted to prescriptions from patients with diagnostic codes F510 (nonorganic insomnia) or G470 (insomnia) were performed. After analyzing the number of prescriptions by individual pharmacy items, the prescription codes were grouped as: (1) benzodiazepines; (2) non-benzodiazepines, including zolpidem; (3) antidepressants; and (4) antipsychotics. We calculated the monthly percent change in the number of prescriptions by drug group using Joinpoint regression. Among the sedative-hypnotic groups, benzodiazepines were the most commonly prescribed drugs in Korea during the study period. As a single sedative-hypnotic item, zolpidem was the most frequently prescribed medication for patients with insomnia. Prescriptions for all groups of sedative-hypnotics increased significantly during the study period. When stratified by age group, antipsychotic prescriptions increased significantly by 0.19-0.21% per month among men and women aged 50-59years and > 70years. Prescriptions for antidepressants in 30-39-year-old men increased significantly by 0.20%. Benzodiazepine prescriptions as well as those for antipsychotics and antidepressants to treat insomnia increased during 2011-2015 in Korea. Monitoring the use of sedative-hypnotics at the national level is necessary, especially in the elderly population.

Linkage of VA and State Prescription Drug Monitoring Program Data to Examine Concurrent Opioid and Sedative-Hypnotic Prescriptions among Veterans.

To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon. VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data. This retrospective cohort study examined concurrent prescriptions among n=19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines). Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program. A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

Evaluation of the Impact of a Multimodel Intervention on Prescribing Patterns of Sedative-Hypnotics in a Behavioral Health System.

To describe the effect of a multimodal intervention targeting chronic benzodiazepine and sedative-hypnotic prescriptions in a large behavioral health system. This retrospective study analyzed chronic sedative-hypnotic prescription rates in patients seeking mental health services in a large behavioral health system. The multimodal intervention consisted of provider education, coordination of care with all providers involved in patient care, and guideline development and implementation for safe prescribing of sedative-hypnotics. Three time periods were analyzed: preintervention (October 2013-December 2013), 12-month assessment (October 2014-December 2014), and 24-month assessment (October 2015-December 2015). The primary outcome of the study was the change in frequency of chronic (≥ 60 days) sedative-hypnotic prescriptions received before and after the multimodal intervention. The secondary outcome included the change in prescription rates in a priori-defined cohorts: patients on methadone maintenance therapy and patients ≥ 60 years of age. There were 32,944 prescriptions during the study period. The rate of chronic sedative-hypnotic prescriptions decreased from 1,764 (15.3%) to 1,634 (14.9%) to 1,018 (9.8%) between the 3 assessment periods, respectively. A significant decrease occurred between the preintervention period and 24-month assessment (5.5%, P < .0001) and between the 12-month assessment and the 24-month assessment (5.1%, P < .0001). In the elderly, prescription rates decreased significantly between the preintervention period and the 24-month assessment (3.6%, P < .0001) and the 12-month and 24-month assessments (3.2%, P = .0001). In patients in methadone maintenance programs, rates of concomitant chronic sedative-hypnotic prescriptions decreased significantly between all assessment periods: preintervention and 12-month assessment (8.2%, P = .001), 12-month and 24-month assessment (6.3%, P = .002), and preintervention and 24-month assessment (14.5%, P < .0001). Additionally, prescription rates increased significantly for antidepressants (4.1%, P < .05), hydroxyzine (1.1%, P = .01), buspirone (2.1%, P < .05), gabapentin (6.3%, P < .05), and melatonin agonists (0.3%, P < .05) between the preintervention and 24-month assessment periods. Implementation of a multimodal intervention led to a significant decrease in rates of chronic sedative-hypnotic prescriptions in a large behavioral health system.

Identifying the Demographic and Mental Health Factors That Influence Insomnia Treatment Recommendations Within a Veteran Population

ABSTRACTObjective/Background: Insomnia is a pervasive and costly disorder that is particularly prevalent within the U.S. Veteran population. Although Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for insomnia, high rates of sedative-hypnotic prescribing continue. There is little research investigating the rates and factors impacting insomnia treatment recommendations, both behavioral and pharmacological. Participants: A cohort of 5,254 Veterans referred for either CBT-I or prescribed a sedative-hypnotic medication at a single VA Medical Center composed the group of participants. Methods: The current study evaluated the rates of insomnia treatment recommendations and the extent to which demographic variables, psychiatric disorders, and sleep disorders contributed to referrals for CBT-I or prescriptions for sedative-hypnotic medications within a large administrative data set. Results: Military service-related disability, insomnia diagnosis, and having one or more psychiatric diagnoses were associated with a greater likelihood of receiving a CBT-I referral (alone or in addition to a sedative-hypnotic medication) rather than a sedative-hypnotic prescription alone. A diagnosis of posttraumatic stress disorder was associated with a greater likelihood of receiving a sedative-hypnotic medication alone versus a CBT-I referral. Conclusions: Overall, the findings suggest that sedative-hypnotic medications were overwhelmingly the primary treatment recommendation despite evidence to support CBT-I as the recommended first-line treatment. However, key factors were identified that increased the likelihood of Veterans being referred for CBT-I. Suggestions for better identifying and understanding key factors that impact treatment recommendations are discussed.

High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among Hospitalized Older Adults.

Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions. To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions. Single-center retrospective observational study. Urban academic medical center. Medical-surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone. Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random-intercept logistic regression model to identify patient- and prescriber-level variables that were associated with potentially inappropriate prescriptions. Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70-16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first-year trainees (OR, 0.28; 95% CI, 0.08-0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21-9.06). The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first-year trainees.Journal of Hospital Medicine 2017;12:310-316.

Risk of psychiatric disorders in patients with chronic insomnia and sedative-hypnotic prescription: a nationwide population-based follow-up study.

Previous epidemiological studies have established insomnia as a major risk factor for mood, anxiety, and substance use disorders. However, the associations between insomnia with sedative-hypnotic prescriptions and various psychiatric disorders have not been thoroughly examined. The current study involved evaluating the risk of psychiatric disorders, namely schizophrenia, mood, anxiety, somatoform, and substance-related disorders, over a 6-y follow-up period in three groups: patients with insomnia and sedative-hypnotic prescriptions (Inso-Hyp), those with insomnia and without sedative-hypnotic prescriptions (Inso-NonHyp), and those with neither insomnia nor sedative-hypnotic prescriptions (NonInso-NonHyp). We used a historical cohort study design to compare the risk of psychiatric disorders among the three groups. Data regarding these patients were derived from reimbursement claims recorded in Taiwan's National Health Insurance Research Database. Cox proportional hazards regression was used to compare the 6-y risk of subsequent psychiatric disorders among the Inso-Hyp, Inso-NonHyp, and NonInso-NonHyp groups. Compared with the Inso-NonHyp and NonInso-NonHyp group patients, the Inso-Hyp group patients exhibited a higher risk of psychiatric disorders, particularly bipolar disorders (adjusted hazard ratio [AHR]: 7.60; 95% confidence interval [CI]: 5.31-10.89 and AHR: 14.69; 95% CI: 11.11-19.43, respectively). Moreover, among the Inso-Hyp patient group, insomnia prescribed with benzodiazepine, a longer duration of sedative-hypnotic action, and higher doses of sedativehypnotics were significantly associated with a higher risk of depressive and anxiety disorders. The Inso-Hyp group exhibited a higher risk of developing psychiatric disorders than did the Inso-NonHyp and NonInso-NonHyp groups. The results regarding patients with insomnia and sedative-hypnotic prescriptions associated with the risk of psychiatric disorders can serve as a reference for care providers when managing sleep disturbances.

The Medicalization of Sleeplessness: A Public Health Concern

Sleeplessness, a universal condition with diverse causes, may be increasingly diagnosed and treated (or medicalized) as insomnia. We examined the trend in sleeplessness complaints, diagnoses, and prescriptions of sedative hypnotics in physician office visits from 1993 to 2007. Consistent with the medicalization hypothesis, sleeplessness complaints and insomnia diagnoses increased over time and were far outpaced by prescriptions for sedative hypnotics. Insomnia may be a public health concern, but potential overtreatment with marginally effective, expensive medications with nontrivial side effects raises definite population health concerns.