1. Epidemiology of Benzodiazepine Prescribing and Use Gerry & Marci’s Story 4 nd Annual Benzodiazepine Conference Portland, Maine 2006

2. J. Gerry Mugford, PhD, CMH Asst. Prof. of Medicine, Pharmacy, & Psychiatry Memorial University of Newfoundland ©JGM 2006 Marcella H. Sorg, RN, PhD Margaret Chase Smith Policy Center University of Maine

3. Credit Where Credit is Due Stevan Gressitt Stevan Gressitt Karen Simone Karen Simone Todd Mandell Todd Mandell Len Kaye Len Kaye Bill Flagg Bill Flagg Office of Substance Abuse, State of Maine Office of Substance Abuse, State of Maine Dorothy Rhodes, IMS Health Dorothy Rhodes, IMS Health Maine Care, Anthem, Express Scripts Maine Care, Anthem, Express Scripts Office of Chief Medical Examiner Office of Chief Medical Examiner

4. Credit Where Credit is Due All contributors to Maine Benzodiazepine Study Group data collection All contributors to Maine Benzodiazepine Study Group data collection All you here today and tomorrow All you here today and tomorrow All those who have made commitments to US/Canada BSG and couldn’t be here All those who have made commitments to US/Canada BSG and couldn’t be here

5. Purpose Today Share information to improve practice So health care providers can make evidenced based decisions to improve quality of patient care Provide information for policy makers to enhance public health and public safety

6. Focus on Research Why more numbers?? Build effective feedback loops between practice and policy to change behavior INFORMATION SYSTEMS New DAWN New Prescription Monitoring Program Monitor change: CONTEXT & PLAYERS CHANGING

7. History Maine Benzodiazepine Study Group created in 2002 –collecting data 5 th. year of data 4 th. year of Annual Benzodiazepine Conferences Published “white papers” summarizing data from diverse links in the benzodiazepine “life cycle” Journal articles under development

8. What is the Context? Use/misuse of pharmaceuticals Gender differences Age differences Focus on Maine, now Vermont & US Building a focus on Canada Repeat the 2005 Physician Survey Snippets of the world

9. Epidemiology: Inform Public Health and Clinical Practice Increased morbidity in particular populations and potential need to screen & treat underlying problem (e.g., anxiety in women) Increased morbidity in particular populations and potential need to screen & treat underlying problem (e.g., anxiety in women) Variation in clinical prescribing practices and potential need to set guidelines (e.g., issues of polypharmacy or long-term treatment) Variation in clinical prescribing practices and potential need to set guidelines (e.g., issues of polypharmacy or long-term treatment) Increased individual and public health risks posed by high prescriptive & misuse prevalence and the potential need to regulate (e.g., driving with BZDs) Increased individual and public health risks posed by high prescriptive & misuse prevalence and the potential need to regulate (e.g., driving with BZDs)

10. Prevalence of Benzodiazepine Prescribing & Usage What numbers are meaningful? What numbers are meaningful? Differences between subpopulations Differences between subpopulations Jurisdictions or cultures with higher use Jurisdictions or cultures with higher use Age groups with higher use Age groups with higher use Gender differences Gender differences What do such differences mean? What do such differences mean? Increased rates of anxiety/insomnia in specific population? Increased rates of anxiety/insomnia in specific population? Differences in clinical prescribing practices? Differences in clinical prescribing practices? Variation in patterns of misuse Variation in patterns of misuse

11. What Patterns are Consistent? (a preview of what we will show) 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

12. BZD Uses Anxiolytic Hypnotic Amnesic Anticonvulsant Myorelaxant

16. 12.8% of enrollees 12.5% of enrollees

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

22. 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+)

23. 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%)

26. Maine Nursing Home Sample “H” 2003-04 Drug Class H Range H Ave. Maine Ave. Anti anxiety12-28%21%18–19% Sedative/hypnot ic 0-8%3%4%

27. Some Nursing Home Estimates Important –Patterns Do Vary! AntianxietyHypnotic Canada12.7%12.2% US15.7%5.0% Low 6.0 % HI1.9% CO/WI High24.0% TN8.5% LA Maine19.4% ME4.3% ME

28. Prevalence National estimates from a diverse sample of countries. 8-10% of the general population takes a BZD each year (de la Cuevas et al 2003)

29. CI: Why Do They Give It? IndicationGlobal % Anxiety48.6 Depression14.4 Agitated Depression9.9 Insomnia16.0 Alcoholism1.7 Organic disorder9.4

30. Is there a problem? Women more likely than men to have prescription–why? (genders more equal for emergency room) 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

31. Is there a problem? Implication in suicide rates in persons >65 as high as 39% [BZD sole agent in 72% of cases] Associated with illicit drug use Associated with substance abuse Associated with automobile accidents [BDZ established main cause] Associated with drug overdose [BDZ established cause]

32. Thank you On to Marci