predictors of the incidence and discontinuation of long-term use … · 2014-10-16 · (hypnotics),...
TRANSCRIPT
-
Chuan-Yu Chen, PhD
Associate Investigator
National Health Research InstitutesInstitute of Population Health and Sciences
Division of Mental Health and Addiction Medicine
Predictors of the incidence and discontinuation of long-term use of benzodiazepines:
A population-based study
-
Team effortsTeam efforts
NHRI: 林克明教授,張憶壽教授
精神組:王聲昌醫師
衛政組:鄭竹珊博士
陳娟瑜、方芍又、葉雪涵
Collaborators 長庚 張家銘醫師
醫療財團法人徐元智先生醫療基金會遠東聯合診所 吳佳璇醫師
亞東醫院 吳其炘醫師
-
A series of research work
Cheng JS, Huang WF, Lin KM, Shih YT. Characteristics associated with benzodiazepine
usage in elderly outpatients in Taiwan. Int J Geriatr Psychiatry. 2008 23:618-24.
Chang CM, Wu ECH, Chang IS, Lin KM. Benzodiazepine and risk of hip fractures in older people: A nested case-control study in Taiwan. American Journal of Geriatric Psychiatry, 2008 16: 686-92.
Wu CS, Wang SC, Chang IS, Lin KM. The association between dementia and long-term use of Benzodiazepine in the elderly: nested case-control study using claims data. American Journal of Geriatric Psychiatry 2009 17: 614-20.
Fang SY, Chen CY, Chang IS, Wu CH, Chang CM, Lin KM. Predictors of the incidence and discontinuation of long-term use of Benzodiazepines: a population-based study. Drug and Alcohol Dependence, 2009.
-
Benzodiazepines (苯二氮平類)
Psychoactive medications
Indications: agitation (sedation), anxiety disorders (anxiolytics), insomnia (hypnotics), epileptic seizure, alcohol withdrawal..
Dose-dependent effects
CNS depressants
One of commonly prescribed medication categories
alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan)--listed among the top 100 most commonly prescribed medication
-
Benzodiazepines (苯二氮平類) Side effects
CNS depressants: psychomotor retardation, cognitive impairment..
Drug and drug/substance interactions
Abuse liability
Tolerance, abuse/dependence, withdrawal
Long-term use
Elderly and underage populations
Sources: prescription and street
-
Benzodiazepines (苯二氮平類)
Non-Benzodiazepines Z-drugs: Zolpidem (佐沛眠, StilnoxStilnox)、 Zopiclone (唑匹可隆Imovane )與
Zaleplon (扎來普隆)
Class of schedule: Schedule III: Brotizolam, Triazolam(小白板),Nimetazepam(一粒
眠),Flunitrazepam (FM2、十字架)
Schedule IV: Diazepam, Alprazolam, Zolpidem, Zopiclone…
-
Source:http://www.nbcd.gov.tw/home/dep/list.aspx?did=200507071156777777777&pid=989
Benzodiazepines: 5~10%
-
Epidemiology of drug-using problems
Model of Disease
Environment
AgentHost
Micro-, exo-, and macro-system (e.g., family, neighborhood, school, peers, media, laws)
Age, sex, race/ethnicity, genetic predisposition, personality trait, life events
Drug type, route of administration, purity, polydrug use..
-
National Health Insurance Policy
Hospital characteristics Hospital level, region, hospital size,
specialty composition, years…
Physician characteristics Specialty, years of training,
gender, case loadings..
Psychotropics characteristics Dose, off-label, indication,
concurrent medication, source (e.g.,hospital or community
pharmacies)Individual characteristics
Age, gender, SES, comorbidity
OutcomeSymptom/injury, service utilization,
drug-related events, cost
Out-of-pocket payment, OTC, street drugs…
Psychotropic medication utilization in the context of single-payer health care system
-
Predictors of the incidence and discontinuation of long-term (LT) use of benzodiazepines (BZDs)
Shao-You Fang, Chuan-Yu Chen, I-Shou Chang, Erin Chia-Hsuan Wu,
Chia-Ming Chang, Keh-Ming Lin
-
Background: LT BZDs1. Prevalence of long-term use; few on incidence
2. Evidence primarily focused on the effects of individual characteristics; little information on organizational or system effects
-
Research aims:To understand individual, service-provider, and
pharmacological factors accounting for the incidence of long-term use and the discontinuity subsequent to extensive long-term use in the general population
-
Methodology Dataset:
1. 2000-2002 National Health Insurance Research Database
2. A random sample of 200,000 individuals drawn in 2000
3. A total of 187,413 individuals was recruited according to their health insurance and survival status.
4. Information on utilization of BZDs in the outpatient visits was retrieved from 2000 to 2002.
-
Methodology Outcome variables:
1. BZD: 24+ 2 Non BZDs
• Alprazolam, bromazepam, brotizolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, cloxazolam, diazepam, estazolam, fludiazepam, flunitrazepam, flurazepam, lorazepam, lormetazepam, medazepam, midazolam, nimetazepam, nitrazepam, nordazepam, oxazepam, oxazolam, prazepam, and triazolam.
• two Z-drugs (zolpidem and zopiclone)
2. Long-term use: 180 prescription days or above in any given calendar year
3. Denominator of incidence: those who hadn’t BZD prescriptions in the preceding year
-
Methodology Predicting variables:
1. Individual background
• Age, gender, enrollee category, physical disorders, mental disorders
2. Service providers
• Level of medical institution, specialty
3. Pharmacological agents
• Indication, half-life, number of BZD agents, use of opioids
-
Results 1:Selected attributes
-
2000(N=187,413) 2001BZD: 2,494(95.23)
Long: 2,121(85.04)
2002
BZD: 34,855(18.60)
Long: 3,650(10.47)
Not long: 31,205(89.53)
BZD: 3,417(93.62)
Longb: 2,619(76.65)
Not long: 798(23.35)
No-BZD: 233(6.38)
BZD: 14,950(47.91)
Long: 1,465(9.80)
No-BZD: 16,255(52.09)
No-BZD: 125(4.77)
BZD: 549(68.80)
No-BZD: 249(31.20)
BZD: 1,350(92.15)
No-BZD: 115(7.85)
No-BZD: 5,404(40.07)
Not long: 13,485(90.20)
Long: 163(29.69)
Not long: 386(70.31)
Long: 891(66.00)
Not long: 459(34.00)
Long: 779(9.64)
Not long: 7,302(90.36)
Not long: 373(14.96)
BZD: 8,081(59.93)
No-BZD: 152,558(81.40)
BZDa: 15,833(10.38)
No-BZD: 136,725(89.62)
Long: 372(2.35)
BZD: 321(86.29)
No-BZD: 51(13.71)
No-BZD: 9,856(63.75)
Not long: 15,461(97.65)
BZD: 5,605(36.25)
Long: 216(67.29)
Not long: 105(32.71)
Long: 474(8.46)
Not long: 5,131(91.54)
BZD: 10,894(7.97)
No-BZD: 125,831(92.03)
Long: 251(2.30)
Not Long: 10,643(97.70)
2000(N=187,413) 2001BZD: 2,494(95.23)
Long: 2,121(85.04)
2002
BZD: 34,855(18.60)
Long: 3,650(10.47)
Not long: 31,205(89.53)
BZD: 3,417(93.62)
Longb: 2,619(76.65)
Not long: 798(23.35)
No-BZD: 233(6.38)
BZD: 14,950(47.91)
Long: 1,465(9.80)
No-BZD: 16,255(52.09)
No-BZD: 125(4.77)
BZD: 549(68.80)
No-BZD: 249(31.20)
BZD: 1,350(92.15)
No-BZD: 115(7.85)
No-BZD: 5,404(40.07)
Not long: 13,485(90.20)
Long: 163(29.69)
Not long: 386(70.31)
Long: 891(66.00)
Not long: 459(34.00)
Long: 779(9.64)
Not long: 7,302(90.36)
Not long: 373(14.96)
BZD: 8,081(59.93)
No-BZD: 152,558(81.40)
BZDa: 15,833(10.38)
No-BZD: 136,725(89.62)
Long: 372(2.35)
BZD: 321(86.29)
No-BZD: 51(13.71)
No-BZD: 9,856(63.75)
Not long: 15,461(97.65)
BZD: 5,605(36.25)
Long: 216(67.29)
Not long: 105(32.71)
Long: 474(8.46)
Not long: 5,131(91.54)
BZD: 10,894(7.97)
No-BZD: 125,831(92.03)
Long: 251(2.30)
Not Long: 10,643(97.70)
-
Association estimates for incident LT BZDs use
-
Association estimates for discontinuation of LT BZDs use
-
Summary Roughly one in 42 ~43 incident users (2.35%) will take BZDs for
180 or more days within any given year; and the rate of complete discontinuation among extensive long-term users is an estimated 4.77%.
Factors in domains of individual sociodemographics, service providers, and pharmacological agents are shown to exert significant effects in the incidence of long-term BZD use.
Only factors pertaining to pharmacological agents appear salient in discontinuation
-
The prescription of BZDs should consider integrate a matrix that reflects different elements in patient and pharmacological characteristics;
Future programs or policies designed to reduce long-term BZD use and associated negative consequences should target certain subpopulations (e.g., the elderly) and address modifiable factors (e.g., prescribing behaviors). Service provider-based monitoring systems may be developed in order to minimize improper medication delivery, including the prescription of BZDs.
-
Thanks for your attentionThanks for your attention