1. Sedative-hypnotic guideline, BHS
Judith Martin, Md
Medical Director of Substance use services, SFDPH

2. Disclosures:
No conflicts of interest for this talk.

3. Quality Management incident reports, 2010-2011 reviewed
55 deaths came to the attention of CBHS during , of patients enrolled in MMT. (most from incident report, collected by Melissa Bloom, QI)
Focused on 14 opioid unintentional overdose deaths of patients in treatment (2 week window)
Tried to obtain medical examiner report
Collateral check of list from Phillip Coffin, Director of SUD Research, who is doing research on all city opioid overdose deaths.

4. 2010/2011 accidental opioid overdose deaths reported by methadone clinics
DOD
LDS/(cls)
Open
Age
Sex
Pgm 1
2005 65 m 2 59 3
1999 70 4
8-3-10
8-1-10
2002 5 f 6 40 7
2-9-11
2-7-11
2008 50 8
2-6-11
2-3-11
2006 60 9
2009 33 10
7mo 46 11
8-5-10
8-4-10 56 12
2007 45 13
1-8-11
2004 61 14
2010

5. Cause of death and tox screen
COD/other me op Bz
sed
coc al
Coc/CVA x
Mixed X Mo
Prom p
Pol/Copd
(OD)
(p) ?
Traz
mOD
Quet Hc
x/m
Poly
Sert,phenob
Sert,quet P
“poly”
mOD/COPd
mOD, Copd

6. Possible areas to address:
8/14 had sedatives present.
8/14 had cocaine present.
Several noted lung disease as a co-morbidity.
( opioid overdose is related to breathing)
Most deaths occurred in patients long into treatment, ie “they’ve been on it for years” isn’t protective, misconceived as safe.

7. Patients receiving buprenorphine at CBHS: Sedative/Hypnotic Prescriptions by CURES report: Michelle Geier, Pharm D

8. Study Findings: Buprenorphine and Sedative/Hypnotic Prescriptions
Results
Number of clients with a sedative or hypnotic
36 (19%)
Average benzodiazepine dose
(clonazepam equivalence)
2.5mg/day
Benzodiazepine dose range
0.25mg – 15mg/day

9. Active Infoscriber Orders Dec 2013
Benzodiazepines and Zolpidem
Comparison
Drug
Number of Active Orders
Risperidone
1914
Trazodone
1623
Bupropion
1308
Sertraline
1277
Aripiprazole
1002
Citalopram
962
Drug
Number of Active Orders
Average Daily Dose (mg)
Clonazepam
1549
1.72
Lorazepam
893
1.74
Zolpidem
574
9.10
Temazepam
138
24.18
Diazepam 68
13.78
Alprazolam 67
1.84

10. Next steps taken:
Presented information to CBHS executive team and to Medication Use Improvement Committee (MUIC) which formed a subgroup that developed a benzodiazepine guideline.
CBHS prescriber quarterly meeting on January 9th dedicated to presenting data, guideline, and getting BHS prescriber responses
CURES registration drive
Implementation varies
Use active prescriptions as measure

11. Highlights of CBHS benzodiazepine guideline: (see handout)
Components:
- using non-sedative options
- risk analysis
- peer consultation
check CURES when prescribing or considering benzodiazepines
Evaluate for opioid use: pain, methadone, buprenorphine, etc.
Evaluate for history of or active substance use disorder, including alcohol.
Evaluate fragility, fall risk, age
Discontinue, taper, consult if above checks positive.