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Epidemiology of Benzodiazepine Prescribing and Use - benzo

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									Epidemiology of Benzodiazepine
Prescribing and Use


5nd Annual Benzodiazepine Study Group
             Conference
            Portland, Maine
                  2007
        Marcella H. Sorg, PhD, RN
     Margaret Chase Smith Policy Center
            University of Maine

         J. Gerry Mugford, PhD, CMH
Asst. Prof. of Medicine, Pharmacy, & Psychiatry
     Memorial University of Newfoundland
Credit Where Credit is Due

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

Why more numbers??
 Build effective feedback loops between
  practice and policy to change behavior
       INFORMATION SYSTEMS

   Monitor change:
       CONTEXT & PLAYERS CHANGING
History

   Maine Benzodiazepine Study Group
    created in 2002 –collecting data
       6th. year of data
       5th. year of Annual Benzodiazepine Study
        Group Conferences
Epidemiology


   Increased morbidity in particular populations
    suggests
       Potential need to screen & treat underlying problem
   Variation in clinical prescribing practices
       Potential need to set guidelines
   Individual and public health risks of prescriptive
    & misuse prevalence
       Potential need to regulate
Context of study includes prescription
drug abuse generally
Conceptual Framework: Inputs

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

Prescriptions
    Females > males
    Older > younger, generally, with peak in 50s
Associated risks
    Accidents: falls, motor vehicle
    Polypharmacy adverse events
    Suicides (multiple drug)
    Illicit drug use (associated with opiates,
     alcohol)
    Drug dependency with long-term use
Prescription Drugs in 2006:
Benzodiazepines
   Among the most common street drugs
   34% of prescriptions for scheduled drugs in
    Maine FY2004 to FY2006 (> 600,000/year)
       68% for persons older than 45, predominantly
        female
   5% of seized samples tested (3% in 2005)
   15% of drug-induced deaths (incl. 9%
    “multiple drug toxicity” with BZD toxicology)
                   Anxiolytic
Amnesic


                  BZD            Hypnotic
                  Uses


 Anticonvulsant          Myorelaxant
Is there a problem?

   Women more likely than men to have
    prescription–why? (genders more equal
    for emergency room, suicides)
   Higher prescribing rates for
    Medicare/Medicaid –why?
   Older age has rates > 2X general
    population for prescriptions (younger
    ages for emergency room)
   24% increase in hip fracture comparing
    seniors take BDZ vs. no BDZ
Baseline Data Collected by the MBSG
            Maine Medicaid Total BZD Users & BZD Scripts

350000
300000
250000
                                                           Total Enrollees
200000
                                                           Total Users
150000
                                                           Total Scripts
100000
50000
    0
         1998 1999 2000 2001 2002 2003 2004 2005
     Maine Medicaid: Number of Scripts per
                  BZD User

10
 9                      12.8% of enrollees
 8
 7
 6
 5                                                Ratio
 4                                 12.5%
 3                                 of enrollees
 2
 1
 0
     1998 1999 2000 2001 2002 2003 2004 2005
                         BZD Prevalence Comparison by Age & Gender
                                Anthem 2003 & Medicaid 2004

                   30
Percent with BZD




                   25
                                                                 FE Anthem 03
                   20
     Script




                                                                 FE Medicaid 04
                   15
                                                                 MA Anthem 03
                   10
                                                                 MA Medicaid 04
                    5
                    0
                        0-9 10- 20- 30- 40- 50- 60- 70- 80+
                            19 29 39 49 59 69 79
                                     Age Group
Express Scripts 2002 (2003)
N = 206,675; n= RS 4,993
 50

 40

 30
                                                Females
 20
                                                Males

 10

  0
      0-9 10- 20-   30- 40- 50-   60- 70- 80+
          19 29     39 49 59      69 79
                                     BZD Prevalence by Age and Gender
                                Anthem 2002 (N=367,907)and 2003 (N=276,101)


                     30.0%
Percent by Age/Sex




                     25.0%
                                                                                 FE 02
     Category




                     20.0%
                                                                                 FE 03
                     15.0%
                                                                                 MA 02
                     10.0%
                                                                                 MA 03
                      5.0%
                      0.0%
                             0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+
                                                 Age Group
Anthem 2003 Highlights

    10% of 2003 subscribers with
     prescriptions had at least 1 prescription
     for a BZD (n=27,308 out of 276,101)
    Of those with a BZD prescription
        4% had a prescription for more than one type
        16% had a prescription for >180 days
        67% of subscribers with a BZD scrip were
         female (similar across age groups 15+)
Note about Express Scripts

   Express Scripts states 2003 rates are
    unlikely to be significantly different from
    2002
       From sample n=8267: 3.3%
       Population size is 206,675 (possibly includes
        subscribers without any prescriptions)
       Possibly does not cover all BZDs (Anthem
        10%)
             Comparison of BZD Prescription Prevalence

Express Scripts
                          3.3
                          3.3


       Anthem                                                          2006
                                                   9.85
                                        6.15                           2005
                                                                       2004
                                                     10.08             2003
   VT-Medicaid
                                                                       2002


                                                          10.76
  ME-Medicaid                                             10.74
                                                   9.75


                  0   2         4   6          8   10             12
              Percent Female Among BZD Prescription
                            Recipients

  Express Scripts % Female

         Anthem % Female                                                 2006
                                                                         2005
NNEPC Poisonings % Female                                                2004
                                                                         2003
     VT-Medicaid % Female                                                2002

    ME-Medicaid % Female


                             0   10   20   30   40   50   60   70   80
The Survey Questions

   Age categories
   Sex categories
   Benzodiazepine categories
   Diagnostic information

   Perennial problem ....the denominator
MBSG Contributions

   Univ. Maine: Drug & Alcohol Research Program data
    contributions involving benzodiazepines
      Office of Chief Medical Examiner (ME,NH,VT)

       Office of Substance Abuse (ME)
       Health & Environmental Testing Laboratory (ME)
   Methadone Clinic Urine Tests
   Outpatient Youth Mental Health
   VT Dept of Corrections
                        OP MH Clinic

30
25
                                               All Males
20
                                               All Females
15
                                               All Males BZD
10
                                               All Females BZD
 5
 0
     0-4        5-9          10-14     15-19


           Prescribing Rate = 7%
Is there a problem?

   Associated with illicit drug use
   Associated with substance abuse
   Associated with suicidal overdose
   Associated with automobile accidents
    [BDZ established main cause]
   Associated with drug overdose [BDZ
    established cause]
National Data
Drug Abuse Warning Network

2004                                   2005
 Benzodiazepines, such as              Benzodiazepines = the most
  alprazolam (34%) &                     prevalent
  clonazepam (18%) were each             psychotherapeutic,
  present in at least 100,000            alprazolam 36% &
  visits involving non-medical           clonazepam 18%
  use of pharmaceuticals:               29% of non-medical use of
  29% of estimated visits                pharmaceuticals
       23% alone- single drug          Increased 19% from ’04 to
       77% poly drug                    ‘05
            30% as one of two drugs
            47% as one of three or
             more
       28% with alcohol
   Age structure: 18% 12-20;
    36% 21-34; 35% 35-54; 10%
    55+
            NSDUH U.S. Data: Percent Reporting
                Tranquilizer Use (Age 12+)

10
 8
                                             Lifetime use
 6
                                             Past year
 4
                                             Past month
 2
 0
     2002    2003   2004 2005    2006
         NSDUH U.S. Data: Percent Reporting
      Tranquilizer Use Past Month by Age Group

2.5
 2
                                                 12-17
1.5
                                                 18-25
 1
                                                 26+
0.5
 0
      2002   2003    2004    2005   2006
MYDAUS: Current non-medical use of prescription
drug in last 30 days

 14.0%
 12.0%
         Younger—more decrease
 10.0%
 8.0%
 6.0%
 4.0%
 2.0%
 0.0%
         6th    7th    8th       9th    10th    11th    12th

  2002   3.2%   4.5%   7.3%      8.8%   10.5%   11.3%   10.2%
  2004   2.8%   3.7%   6.1%      8.9%   11.0%   11.6%   10.3%
  2006   1.8%   2.0%   3.8%      6.2%   8.1%    9.5%    9.4%
DAWN Mortality

   Benzodiazepines are in the top 5 involved in
    drug-related deaths in 29/32 metro areas and
    5/6 states
   Among suicides, benzodiazepines rank first
    1/32 metro areas and among the top 5 in
    19/32 metro areas and 2/6 states
    Benzodiazepines in Emergency Department
    Visits (DAWN, US, 2002)
   Over 100,000 drug abuse-related emergency
    department visits involving BZDs in 2002
       41% increase since 1995
   78% involve more than one drug
   Approx. half are suicide attempts
   Visits increasing for BZD
     Dependence
     Psychic effects
 NOTE THAT DAWN CHANGED-CAN’T
    COMPARE
    Benzodiazepines in US Emergency Department
    Visits, 2002

   AGE
      Highest rate: 26-44
      Lowest rate: 12 –17 and 55+
      Greatest increase since 1995: age 18-19
 GENDER
      No gender differences in rates   (N.B.)
      Not sure why
    Benzodiazepines in US Emergency
    Department Visits, 2002
   Most frequent: Pattern continues
     Alprazolam [Xanax]

     Clonazepam [Klonopin,Clonopin]

   78% involved > 1 drug: Pattern continues
   Substances most often reported with BZDs Pattern
    continues
     Narcotic analgesics

     Alcohol

     Marijuana
            ED Visits Involving Benzodiazepines (DAWN)

110000
105000
100000
 95000
 90000
 85000
 80000
               1998      1999      2000      2001        2002
ED Visits     88808      90539     91078     103972      105752

            Large increase beginning in early 2000’s
DAWN US 2004

       106 million ED visits. during 2004
         1,997,993 were drug-related –about 2%
       Nearly 1.3 million associated with drug misuse or
        abuse (Most)
         30% involved illicit drugs only,
         25% involved pharmaceuticals only,
         15% involved illicit drugs and alcohol,
         8% involved illicit drugs with pharmaceuticals, and
         14% involved illicit drugs with pharmaceuticals and
          alcohol.
ED Visits Related to Pharmaceutical
Misuse/Abuse, 2004
   > 56% of suicide-related visits included psychotherapeutic
    agents, such as benzodiazepines or antidepressants
       Alprazolam in 49,842 visits
       Clonazepam in 26,238 visits
       Diazepam in 15,733 visits
       Lorazepam in 16,926 visits
   37,081 visits BZS no specific ingredient named
Anxiolytics, sedatives, and   175,115
hypnotics

Benzodiazepines               144,385


Alprazolam                    49,842


Clonazepam                    26,238


Lorazepam                     16,926


Diazepam                      15,733


Benzodiazepines- NOS          37,081
Treatment Admissions
      Maine TDS: Number of Admissions and Unduplicated
       Clients with Benzodiazepines a Primary Problem

120

100

80
                                                 Clients
60
                                                 Admissions
40

20

 0
      2000   2001   2002   2003   2004   2005
        Maine TDS: Number of Primary, Secondary, & Tertiary
              Benzodiazepine Admissions, 2000-2005

600

500
                                                  Primary Admissions
400

                                                  Secondary & Tertiary
300
                                                  Admissions

200                                               Total

100

 0
      2000   2001   2002   2003   2004   2005
Maine TDS 2004-2005: Unduplicated Clients Admitted for
Primary Problem of Benzodiazepines Compared with all
TDS Clients Admitted (N=125)
                                 BZD Clients   TDS Clients

% Female                         55%           33%

Mean age                         37            33

Mean age 1st use                 27            17

% Single/never married           46%           53%

% > High school education        34%           21%

% Domestic violence victim       30%           19%

% Medical treatment ED past yr   63%           43%
Maine TDS 2004-2005: Unduplicated Clients Admitted for
Primary Problem of Benzodiazepines Compared with all
TDS Clients Admitted (N=125)
                               BZD Clients   TDS Clients

% Treated OP mental health     45%           23%

% Opioid replacement therapy   12%           17%

% Arrested past year           37%           44%

% Arrested non-OUI substance   20%           21%
2004
      TEDS: Admissions for Benzodiazepines in States with Top-5
               Highest Rates Per 100,000 Population

600


500


400                                                               KY
                                                                  LA
300                                                               MA
                                                                  ME
200                                                               RI


100


 0
      2000        2001        2002        2003         2004
Deaths
Maine Drug-Induced Deaths
                                                                  647%
160                                                             INCREASE
140
120
100
80
60
40
20
 0
      1997   1998   1999   2000   2001    2002   2003   2004   2005 2006est

                              Accidents    Suicides
Deaths
Pharmaceutical-Induced/Related & Others
 160



 140



 120



 100
                                                                      Pharm.
                                                                      Narcotics
                                                                      Benzo.
  80                                                                  Illicit
                                                                      Alcohol
  60



  40



  20



  0


       1997   1998   1999   2000   2001   2002   2003   2004   2005
Maine Drug-Related Deaths

   About one-third have BZD in their toxicology
    reports
   About 12% have BZD cause of death
       NH 20%
       VT 13%
       NC 2%
   Another 5% have “polydrug” cause with BZD
    toxicology
       Number and Percent of Maine Drug-Related
           Deaths Due to Benzodiazepines

20
18
16
14
12                                                BZD& Other
10                                                BZD Alone
8                                                 BZD % of All
6
4
2
0
     2002      2003       2004      2005
Benzodiazepine Deaths 2002-2005

   67 BZD deaths
     12% of deaths, 17% including “mixed drug” with BZD

      present in toxicology
     4 (6%) caused by BZD alone

   63 (94%) caused by BZD + other drugs or alcohol
   61% narcotics (49% methadone, 18%
    morphine/heroin)
   9% with alcohol
   6% with cocaine
   33%=alprazolam; 36%=diazepam
            NH: Number of Deaths Caused by
                    Benzodiazepines
                 Problem of small numbers
35                                            35 (21%)
30

25
20
15
10
5
0
     2000     2001    2002     2003    2004     2005
                             What’s the Problem???
Visible, Indirect
Indicators           Deaths, ED
                  Visits, Treatment
                 Admissions, Falls,
               Motor Vehicle Accidents,
                 Lost Days at Work

         Practice Guidelines, Professional
         Culture, Prescription Monitoring,
      Medical Reimbursement &Timing for a
   Therapeutic Visit, Patient & Provider Education
                Less Visible, More Direct,
                Harder to Measure
                  PANDORA’S BOX


Prescribing issues             Diversion issues
   •Unnecessary                   •Drug dealing
   •Not the best drug             •Drug sharing
   •Too long
   •No alternative             Pharmacology issues
   •Un-used meds                  •Drug interactions
   •Multiple providers            •Polypharmacy
   •Lack of knowledge

Policy issues                   Law enforcement issues
    •Controlled substance?         •Officer knowledge
    •Prescription monitoring       •Punishment
    •Disposal unused meds          •Perceived severity
Pharmaceutical Misuse & Abuse

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

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

								
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