Epidemiology of Benzodiazepine Prescribing and Use

1. Epidemiology of Benzodiazepine Prescribing and Use 5nd Annual Benzodiazepine Study Group Conference Portland, Maine 2007

2. 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

3. 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

4. Focus on Research Why more numbers?? • Build effective feedback loops between practice and policy to change behavior • INFORMATION SYSTEMS • Monitor change: • CONTEXT & PLAYERS CHANGING

5. History • Maine Benzodiazepine Study Group created in 2002 –collecting data • 6th. year of data • 5th. year of Annual Benzodiazepine Study Group Conferences

6. 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

7. Context of study includes prescription drug abuse generally

8. 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

9. 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

10. 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)

11. Anxiolytic Amnesic Hypnotic BZD Uses Myorelaxant Anticonvulsant

12. 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

13. Baseline Data Collected by the MBSG

15. 12.8% of enrollees 12.5% of enrollees

17. Express Scripts 2002 (2003)N = 206,675; n= RS 4,993

19. 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+)

20. 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%)

23. The Survey Questions • Age categories • Sex categories • Benzodiazepine categories • Diagnostic information • Perennial problem ....the denominator

24. 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

25. Prescribing Rate = 7%

26. 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]

27. National Data

28. 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 23% alone- single drug 77% poly drug 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 Drug Abuse Warning Network

31. MYDAUS: Current non-medical use of prescription drug in last 30 days Younger—more decrease

32. 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

33. Benzodiazepines in EmergencyDepartment 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

34. 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

35. 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

36. Large increase beginning in early 2000’s

37. 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.

38. 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

40. Treatment Admissions

43. Maine TDS 2004-2005: Unduplicated Clients Admitted for Primary Problem of Benzodiazepines Compared with all TDS Clients Admitted (N=125)

44. Maine TDS 2004-2005: Unduplicated Clients Admitted for Primary Problem of Benzodiazepines Compared with all TDS Clients Admitted (N=125)

45. 2004

47. Deaths

48. Maine Drug-Induced Deaths 647% INCREASE

49. 160 140 120 Pharm. 100 Narcotics Benzo. Illicit 80 Alcohol 60 40 20 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 DeathsPharmaceutical-Induced/Related & Others

50. 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