Transcript Epidemiology of Benzodiazepine Data Update

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
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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
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INFORMATION SYSTEMS
Monitor change:
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CONTEXT & PLAYERS CHANGING
History
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Maine Benzodiazepine Study Group
created in 2002 –collecting data
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6th. year of data
5th. year of Annual Benzodiazepine Study
Group Conferences
Epidemiology
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Increased morbidity in particular populations
suggests
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Variation in clinical prescribing practices
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Potential need to screen & treat underlying problem
Potential need to set guidelines
Individual and public health risks of prescriptive
& misuse prevalence
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Potential need to regulate
Context of study includes prescription
drug abuse generally
Conceptual Framework: Inputs
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Increasing use of pharmaceuticals
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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
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Females > males
Older > younger, generally, with peak in 50s
Associated risks
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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
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Among the most common street drugs
34% of prescriptions for scheduled drugs in
Maine FY2004 to FY2006 (> 600,000/year)
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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
Uses
Anticonvulsant
Hypnotic
Myorelaxant
Is there a problem?
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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
8
7
6
5
4
3
2
1
0
12.8% of enrollees
Ratio
12.5%
of enrollees
1998 1999 2000 2001 2002 2003 2004 2005
Percent with BZD
Script
BZD Prevalence Comparison by Age & Gender
Anthem 2003 & Medicaid 2004
30
25
FE Anthem 03
20
15
10
FE Medicaid 04
MA Anthem 03
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
Males
20
10
0
0-9 10- 2019 29
30- 40- 5039 49 59
60- 70- 80+
69 79
Percent by Age/Sex
Category
BZD Prevalence by Age and Gender
Anthem 2002 (N=367,907)and 2003 (N=276,101)
30.0%
25.0%
FE 02
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
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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
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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
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Express Scripts states 2003 rates are
unlikely to be significantly different from
2002
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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
2006
Anthem
9.85
6.15
2005
2004
2003
10.08
VT-Medicaid
2002
10.76
10.74
ME-Medicaid
9.75
0
2
4
6
8
10
12
Percent Female Among BZD Prescription
Recipients
Express Scripts % Female
2006
Anthem % Female
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
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Age categories
Sex categories
Benzodiazepine categories
Diagnostic information
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Perennial problem ....the denominator
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MBSG Contributions
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Univ. Maine: Drug & Alcohol Research Program data
contributions involving benzodiazepines
 Office of Chief Medical Examiner (ME,NH,VT)
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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
Prescribing Rate = 7%
15-19
Is there a problem?
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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
 Benzodiazepines, such as
alprazolam (34%) &
clonazepam (18%) were each
present in at least 100,000
visits involving non-medical
use of pharmaceuticals:
29% of estimated visits
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23% alone- single drug
77% poly drug
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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+
2005
 Benzodiazepines = the most
prevalent
psychotherapeutic,
alprazolam 36% &
clonazepam 18%
 29% of non-medical use of
pharmaceuticals
 Increased 19% from ’04 to
‘05
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
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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)
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Over 100,000 drug abuse-related emergency
department visits involving BZDs in 2002
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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
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AGE
Highest rate: 26-44
 Lowest rate: 12 –17 and 55+
 Greatest increase since 1995: age 18-19
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 GENDER
 No gender differences in rates
 Not sure why
(N.B.)
Benzodiazepines in US Emergency
Department Visits, 2002
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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
ED Visits
1998
1999
2000
2001
2002
88808
90539
91078
103972
105752
Large increase beginning in early 2000’s
DAWN US 2004
106 million ED visits. during 2004
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1,997,993 were drug-related –about 2%
Nearly 1.3 million associated with drug misuse or
abuse (Most)
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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
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> 56% of suicide-related visits included psychotherapeutic
agents, such as benzodiazepines or antidepressants
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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
hypnotics
175,115
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
300
Secondary & Tertiary
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
RI
200
100
0
2000
2001
2002
2003
2004
Deaths
Maine Drug-Induced Deaths
647%
INCREASE
160
140
120
100
80
60
40
20
0
1997
1998
1999
2000
2001
Accidents
2002
2003
Suicides
2004
2005 2006est
Deaths
Pharmaceutical-Induced/Related & Others
160
140
120
Pharm.
Narcotics
Benzo.
Illicit
Alcohol
100
80
60
40
20
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
Maine Drug-Related Deaths
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About one-third have BZD in their toxicology
reports
About 12% have BZD cause of death
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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
6
BZD % of All
4
2
0
2002
2003
2004
2005
Benzodiazepine Deaths 2002-2005
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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
•Unnecessary
•Not the best drug
•Too long
•No alternative
•Un-used meds
•Multiple providers
•Lack of knowledge
Policy issues
•Controlled substance?
•Prescription monitoring
•Disposal unused meds
Diversion issues
•Drug dealing
•Drug sharing
Pharmacology issues
•Drug interactions
•Polypharmacy
Law enforcement issues
•Officer knowledge
•Punishment
•Perceived severity
Pharmaceutical Misuse & Abuse
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Must be examined in combination with illicit
drug abuse
Multiple forms
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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
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Diversion probably increasing (poisonings)
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Not well monitored in law enforcement
Great variation between states (deaths,
treatment)
Mortality risk is rising with polypharmacy use
Prescribers play a central role