Epidemiology of Benzodiazepine Prescribing and UseGerry & Marci’s Story

4nd Annual Benzodiazepine Conference

Portland, Maine2006

J. Gerry Mugford, PhD, CMHAsst. Prof. of Medicine, Pharmacy, & Psychiatry

Memorial University of Newfoundland©JGM 2006

Marcella H. Sorg, RN, PhDMargaret Chase Smith Policy Center

University of Maine

Credit Where Credit is Credit Where Credit is DueDue

Stevan GressittStevan Gressitt Karen SimoneKaren Simone Todd MandellTodd Mandell Len KayeLen Kaye Bill FlaggBill Flagg Office of Substance Abuse, State of MaineOffice of Substance Abuse, State of Maine Dorothy Rhodes, IMS HealthDorothy Rhodes, IMS Health Maine Care, Anthem, Express ScriptsMaine Care, Anthem, Express Scripts Office of Chief Medical ExaminerOffice of Chief Medical Examiner

Credit Where Credit is Credit Where Credit is DueDue

All contributors to Maine All contributors to Maine Benzodiazepine Study Group Benzodiazepine Study Group data collectiondata collection

All you here today and tomorrowAll you here today and tomorrow All those who have made All those who have made

commitments to US/Canada BSG commitments to US/Canada BSG and couldn’t be hereand couldn’t be here

Focus on ResearchFocus 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

HistoryHistory

Maine Benzodiazepine Study Group created in 2002 –collecting data 5th. year of data 4th. year of Annual Benzodiazepine

Conferences Published “white papers”

summarizing data from diverse links in the benzodiazepine “life cycle”

Journal articles under development

Epidemiology: Inform Epidemiology: Inform Public Health and Clinical Public Health and Clinical

PracticePractice Increased morbidity in particular Increased morbidity in particular

populations and populations and potential need to screen & potential need to screen & treat underlying problem treat underlying problem (e.g., anxiety in (e.g., anxiety in women)women)

Variation in clinical prescribing practices Variation in clinical prescribing practices and and potential need to set guidelines potential need to set guidelines (e.g., (e.g., issues of polypharmacy or long-term issues of polypharmacy or long-term treatment) treatment)

Increased individual and public health risks Increased individual and public health risks posed by high prescriptive & misuse posed by high prescriptive & misuse prevalence and the prevalence and the potential need to potential need to regulateregulate (e.g., driving with BZDs) (e.g., driving with BZDs)

What Patterns are What Patterns are Consistent? Consistent?

(a preview of what we will (a preview of what we will show)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

BZDUses

Anxiolytic

Hypnotic

Amnesic

Anticonvulsant

Myorelaxant

NNEPC: Maine BZD Citings, Human Poisoning Exposures by Gender

0

100

200

300

400

500

600

700

800

2002 2003 2004 2005 2006est

Female

Male

Unknown

Total

NNEPC: Maine BZD Citings, Information Calls by Gender

0500

1,0001,5002,0002,5003,0003,5004,0004,5005,000

2002 2003 2004 2005 2006est

Female

Male

UNK/INV

Total

Maine Medicaid Total BZD Users & BZD Scripts

0

50000

100000

150000

200000

250000

300000

350000

1998 1999 2000 2001 2002 2003 2004 2005

Total Enrollees

Total Users

Total Scripts

Maine Medicaid: Number of Scripts per BZD User

0123456789

10

1998 1999 2000 2001 2002 2003 2004 2005

Ratio

12.8% of enrollees

12.5%of enrollees

Vermont Medicaid: Enrollees with Paid BZD Claims

0

500

1,000

1,500

2,000

2,500

Males

Females

Total

BZD Prevalence Comparison by Age & GenderAnthem 2003 & Medicaid 2004

0

5

10

15

20

25

30

0-9 10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Age Group

Perc

ent w

ith B

ZD

Scrip

t

FE Anthem 03

FE Medicaid 04

MA Anthem 03

MA Medicaid 04

Express Scripts 2002 Express Scripts 2002 (2003)(2003)

N = 206,675; n= RS 4,993N = 206,675; n= RS 4,993

0

10

20

30

40

50

0-9 10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Females

Males

BZD Prevalence by Age and Gender

Anthem 2002 (N=367,907)and 2003 (N=276,101)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+

Age Group

Perc

ent b

y Age

/Sex

Ca

tego

ry

FE 02

FE 03

MA 02

MA 03

US Per Capita Retail Scripts: Age/Gender

0

10

20

30

40

50

US 8.1 13.8 20.8 28.9

Maine 8.4 14.2 17.1 20.4

TN 13.3 22.9 29.5 41.6

19-64 19-64 65+ 65+

Males Females Males Females

Anthem 2003 HighlightsAnthem 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+)

Note about Express Note about Express ScriptsScripts

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%)

Comparison of BZD Prescription Prevalence

9.75

6.15

3.3

9.85

3.3

10.7410.76

10.08

0 2 4 6 8 10 12

ME-Medicaid

VT-Medicaid

Anthem

Express Scripts

2006

2005

2004

2003

2002

Percent Female Among BZD Prescription Recipients

0 10 20 30 40 50 60 70 80

ME-Medicaid % Female

VT-Medicaid % Female

NNEPC Poisonings % Female

Anthem % Female

Express Scripts % Female

2006

2005

2004

2003

2002

Maine Nursing Home Maine Nursing Home Sample “H” 2003-04Sample “H” 2003-04

DrugClass

HRange

H Ave.

MaineAve.

Anti anxiety 12-28% 21% 18–19%

Sedative/hypnotic

0-8% 3% 4%

Some Nursing Home Some Nursing Home EstimatesEstimates

Important –Patterns Do Important –Patterns Do Vary!Vary!Antianxiety Hypnotic

Canada 12.7% 12.2%

US 15.7% 5.0%

Low 6.0 % HI 1.9% CO/WI

High 24.0% TN 8.5% LA

Maine 19.4% ME 4.3% ME

CI: Why Do They Give It?CI: Why Do They Give It?

Indication Global %

Anxiety 48.6

Depression 14.4

Agitated Depression 9.9

Insomnia 16.0

Alcoholism 1.7

Organic disorder 9.4

Is there a problem?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

Is there a problem?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]

Thank youThank youOn to MarciOn to Marci