Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting

ABSTRACT

Background: Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. Methods: Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. Results: In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. Conclusions: Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.     

Antipsychotic prescribing in Black and White hospitalised patients

Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical antipsychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) -4.28, 6.22], p = 0.72); high dose (adjusted odds ratio (AOR) 0.98 [CI 0.63, 1.51], p = 0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p = 0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49], p = 0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p = 0.22); and cost (adjusted effect size 1.75 [CI -9.81, 13.31], p = 0.77). Antipsychotic prescribing practice did not differ between Black and White patients.     

Incidence and possible causes of prescribing potentially hazardous/contraindicated drug combinations in general practice.

BACKGROUND: Preventing the use of medications where there is the potential for serious drug-drug interactions or drug-disease interactions (contraindications) is essential to ensure patient safety. Previous studies have looked at the incidence of prescribing contraindicated drug combinations, but little is known about the underlying reasons for the co-prescribing events. The objectives of this study were to estimate the incidence of prescribing contraindicated drug combinations in general practice and to explore the clinical context, possible causes and potential systems failures leading to their occurrence. METHODS: A list of contraindicated drug combinations was compiled according to established references. A search of computerised patient medication records was performed, followed by detailed chart review and assessment. The patient records from four general practices in an area of England were searched for a period of 1 year (1 June 1999-31 May 2000) to identify contraindicated drug combinations. All patients registered with the four participating practices during the study period were included (estimated n = 37 940). Medical records of the cases identified by the computer search were reviewed in detail and relevant information was extracted. Each case was then independently assessed by a pharmacist and a physician who judged whether the co-prescribing was justified and whether it was associated with an adverse drug event. Proximal causes and potential systems failures were suggested for each co-prescribing event. MAIN OUTCOME MEASURES AND RESULTS: Fourteen patients with potential drug-drug interactions and 50 patients with potential drug-disease interactions were identified. Overall, these represent an incidence of 1.9 per 1000 patient-years (95% CI 1.5, 2.3) or 4.3 per 1000 patients being concurrently prescribed > or =2 drugs per year (95% CI 3.2, 5.4). 62 cases involving 63 co-prescribing events were reviewed. Two-thirds of these events involved medications that were initiated by hospital doctors. Awareness of the potential drug-drug or drug-disease interactions was documented in one-third of the events at the time of initial co-prescribing. Within the study period, the co-prescribing was judged to be not justified in 44 events (70%). Potential drug-drug interactions possibly resulted in two adverse drug events. The majority of contraindicated co-prescribing related to drug-disease interactions involved the use of propranolol or timolol eye drops for patients receiving bronchodilators and the use of amiodarone for patients receiving levothyroxine sodium. CONCLUSION: The prescribing of contraindicated drug combinations was relatively rare in this study. Multiple possible causes and systems failures were identified and could be used to develop strategies for the prevention of prescribing errors involving contraindicated drug combinations in primary care.     

Adults who misuse opioids: Substance abuse treatment use and perceived treatment need

Background: Opioid use disorder (OUD) and overdose deaths among the US population continue to increase. This study examined associations of OUD and other substance use disorders with substance abuse treatment use and perceived treatment need among US adults aged 18+ who misused opioids. Methods: The 2015–2016 National Survey on Drug Use and Health provided data (n?=?5100 respondents who misused opioids in the past year). We used multivariable logistic regression models to examine associations of opioid and other substance use disorders with treatment use and perceived treatment need, adjusting for sociodemographic and health statuses. Results: The data showed that 4.7% of adults misused opioids and 19.1% of those who misused had an OUD. Of those with an OUD, only 31.5% had received substance abuse treatment in the past year and 13.6% perceived the need for such treatment. Of those with an OUD, heroin use disorder (adjusted odds ratio [AOR]?=?2.59, 95% confidence interval [CI]?=?1.59–4.23) and having been arrested/booked (AOR?=?1.98, 95% CI?=?1.18–3.33) were associated with higher odds of receiving treatment, whereas lack of health insurance (AOR?=?0.49, 95% CI?=?0.25–0.94) was associated with lower odds. Heroin use disorder (AOR?=?2.16, 95% CI?=?1.23–3.83) and higher mental health impairment scores (AOR?=?1.05, 95% CI?=?1.01–1.09) were associated with higher odds of perceived treatment need. Conclusions: The overall low socioeconomic status and high rates of polysubstance use disorders among those with OUD indicate that they need financial and other help to access treatment and relapse prevention services. The very low rates of perceived treatment need also point to the need for strategies to increase individuals’ recognition of their need for treatment.     

Lifetime Doctor-Diagnosed Mental Health Conditions and Current Substance Use Among Gay and Bisexual Men Living in Vancouver,Canada

Background: Studies have found that gay, bisexual, and other men who have sex with men (GBM) have higher rates of mental health conditions and substance use than heterosexual men, but are limited by issues of representativeness. Objectives: To determine the prevalence and correlates of mental health disorders among GBM in Metro Vancouver, Canada. Methods: From 2012 to 2014, the Momentum Health Study recruited GBM (≥16 years) via respondent-driven sampling (RDS) to estimate population parameters. Computer-assisted self-interviews (CASI) collected demographic, psychosocial, and behavioral information, while nurse-administered structured interviews asked about mental health diagnoses and treatment. Multivariate logistic regression using manual backward selection was used to identify covariates for any lifetime doctor diagnosed: (1) alcohol/substance use disorder and (2) any other mental health disorder. Results: Of 719 participants, 17.4% reported a substance use disorder and 35.2% reported any other mental health disorder; 24.0% of all GBM were currently receiving treatment. A lifetime substance use disorder diagnosis was negatively associated with being a student (AOR = 0.52, 95% CI [confidence interval]: 0.27–0.99) and an annual income ≥$30,000 CAD (AOR = 0.38, 95% CI: 0.21–0.67) and positively associated with HIV-positive serostatus (AOR = 2.54, 95% CI: 1.63–3.96), recent crystal methamphetamine use (AOR = 2.73, 95% CI: 1.69–4.40) and recent heroin use (AOR = 5.59, 95% CI: 2.39–13.12). Any other lifetime mental health disorder diagnosis was negatively associated with self-identifying as Latin American (AOR = 0.25, 95% CI: 0.08–0.81), being a refugee or visa holder (AOR = 0.18, 95% CI: 0.05–0.65), and living outside Vancouver (AOR = 0.52, 95% CI: 0.33–0.82), and positively associated with abnormal anxiety symptomology scores (AOR = 3.05, 95% CI: 2.06–4.51). Conclusions: Mental health conditions and substance use, which have important implications for clinical and public health practice, were highly prevalent and co-occurring.     

Does this patient really want treatment? Factors associated with baseline and evolving readiness for change among hospitalized substance using adults interested in treatment

Little is known about motivation for treatment and readiness for change during an acute medical event. We present data from a cohort of 353 actively substance abusing adults assessed at baseline and every three days during their hospital admission for readiness to change substance use behaviors (URICA), self-reported motivations for substance abuse treatment, and pain and withdrawal symptoms. Factors independently associated with being in a higher (i.e., contemplation or action) stage of change included female sex (AOR=2.33; 95% CI: 1.42, 3.81), being on probation or parole (AOR=2.55; 95% CI: 1.32, 4.93), bipolar disorder (AOR 2.60; 95% CI: 1.20, 5.63), believing they would get sick again if drug use continued (AOR=2.24; 95% CI: 1.36, 3.70), being "tired of using" (AOR=2.91; 95% CI: 1.21, 6.96) and family concerns (AOR=1.78; 95% CI: 1.08, 2.96). During their hospitalization 43.6% increased from precontemplation or contemplation to a higher stage or remained in the action stage. Believing one would get sick again if substance use continued (AOR=2.42; 95% CI: 1.07, 5.48), physical health concerns (AOR=5.28; 95% CI: 1.36, 20.44) and citing "tired of using" as a primary motivator (AOR=2.88; 95% CI: 1.10, 7.54) were independently associated with increased stage of change.     

Benzodiazepine use in an elderly community-dwelling population. Characteristics of users and factors associated with subsequent use

OBJECTIVES: The objective of this study was to describe determinants of current and subsequent benzodiazepine use in an elderly population, the Paquid cohort. METHODS: The study was conducted on a cohort of 2,792 community-dwelling subjects 65 years of age or more living in the Gironde department, southwestern France. Benzodiazepine use and its correlates were studied with data collected at inclusion in the cohort. Longitudinal analysis over a 5-year period of follow-up was done to identify baseline predictors of subsequent use. RESULTS: At baseline, prevalence rate of benzodiazepine use was 31.9%. It was associated with female gender [odds ratio (OR) = 2.0; 95% confidence interval (CI): 1.66, 2.46], previous psychiatric disease (OR = 2.87; 95% CI: 2.31, 3.56), concomitant antidepressant use (OR = 2.45; 95% CI: 1.59, 3.78), depressive symptomatology (OR = 1.70; 95% CI: 1.28, 2.26), multiple drug use (OR = 1.82; 95% CI: 1.50, 2.21), multiple chronic diseases (OR = 1.37; 95% CI: 1.12, 1.67) and poor self-perceived health (OR = 1.63; 95% CI: 1.33, 2.0). For the 1926 benzodiazepine non-users at inclusion and followed during 5 years, incidence rate of subsequent use was 5.37 per 100 person-years (95% CI: 4.76, 5.98). In multivariate Cox proportional hazards regression analysis, previous psychiatric diseases, poor self-perceived life satisfaction and polymorbidity were significantly associated with subsequent benzodiazepine use. CONCLUSIONS: Elderly people are heavy users of benzodiazepines. Independently from mental health status, those in poor health were most at risk of benzodiazepine use.     

Correlates of Skin and Soft Tissue Infections in Injection Drug Users in a Syringe-Exchange Program in Malmö, Sweden

Background: Injection drug users (IDUs) are at increased risk of various medical conditions, including bacterial skin and soft tissue infections (SSTIs). SSTIs, which are painful and can lead to life-threatening complications, are common but scarcely studied. Objectives: To investigate life time, past 12 month and past 30-day prevalence for SSTI related to injection drug use, in IDUs at Malmö syringe exchange program (Malmö SEP). To investigate factors associated with having ever had an SSTI. Methods: IDUs were recruited from Malmö SEP (N = 80). They participated in a survey with questions about demographics, drug use, and experience of SSTIs. Factors independently associated with self-reported SSTI ever were assessed using logistic regression analysis. Results: The lifetime reported prevalence of SSTI was 58%, past 12 months 30%, and past 30 days 14%. Factors independently associated with SSTI ever were age (adjusted odds ratio [AOR] = 1.09; 95% confidence interval [CI] = 1.01–1.18), female sex (AOR = 6.75; 95% CI = 1.40–32.47), having ever injected prescribed drugs (AOR = 52.15; 95% CI = 5.17–525.67), and having ever injected in the neck (AOR = 8.08; 95% CI = 1.16–56.08). Conclusions/Importance: SSTI is common among IDUs in Malmö. Women and those injecting in the neck or injecting prescribed drugs (crushed tablets/liquids), are more likely to have had an SSTI.     

Interest in using mobile technology to help self-manage alcohol use among persons living with the human immunodeficiency virus: A Florida Cohort cross-sectional study

ABSTRACT

Background: Alcohol consumption at hazardous levels is more prevalent and associated with poor health outcomes among persons living with the human immunodeficiency virus (HIV; PLWH). Although PLWH are receptive to using technology to manage health issues, it is unknown whether a cell phone app to self-manage alcohol use would be acceptable among PLWH who drink. The objectives of this study were to determine factors associated with interest in an app to self-manage drinking and to identify differences in baseline mobile technology use among PLWH by drinking level. Methods: The study population included 757 PLWH recruited from 2014 to 2016 into the Florida Cohort, an ongoing cohort study investigating the utilization of health services and HIV care outcomes among PLWH. Participants completed a questionnaire examining demographics, substance use, mobile technology use, and other health behaviors. Multivariable logistic regression was used to identify factors significantly associated with interest in an app to self-manage drinking. We also determined whether mobile technology use varied by drinking level. Results: Of the sample, 40% of persons who drink at hazardous levels, 34% of persons who drink at nonhazardous levels, and 19% of persons who do not drink were interested in a self-management app for alcohol use. Multivariable logistic regression analysis indicated that nonhazardous drinking (adjusted odds ratio [AOR] = 1.78; confidence interval [CI 95%]: 1.10–2.88) and hazardous drinking (AOR = 2.58; CI: 1.60–4.16) were associated with interest, controlling for age, gender, education, and drug use. Regarding mobile technology use, most of the sample reported smartphone ownership (56%), text messaging (89%), and at least one cell phone app (69%). Conclusions: Regardless of drinking level, overall mobile technology use among PLWH was moderate, whereas PLWH who consumed alcohol expressed greater interest in a cell phone app to self-manage alcohol use. This indicates that many PLWH who drink would be interested in and prepared for a mobile technology–based intervention to reduce alcohol consumption.     

Factors identifying high-frequency and low-frequency health service utilization among substance-using adults

Understanding why substance-using patients seek care at emergency departments (EDs) and who utilizes such service at high rates is important in tailoring and targeting interventions. We conducted a retrospective/prospective cohort study of 326 medically ill substance-using adults to identify factors associated with 12-month high-frequency utilization of ambulatory care, ED, and inpatient medical care. The majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%); 94.8% had a chronic medical condition; and 53.8% reported a chronic mental health condition. High-frequency use of ED (> or = 3 visits) was independently associated with being female (adjusted odds ratio [AOR] = 1.88; 95% confidence interval [95% CI] = 1.12, 3.17), being African American (AOR = 2.36; 95% CI = 1.30, 4.29), being homeless (AOR = 2.07; 95% CI = 1.08, 3.96), a history of > 1 substance abuse treatment episode (AOR = 4.10; 95% CI = 3.28, 10.87), and > or = 1 ambulatory care visit (AOR = 8.94; 95% CI = 3.28, 24.41). However, the combination of having certain chronic conditions (seizure disorder, hepatitis B, and hepatitis C) and accessing ambulatory care was protective against high-frequency use of ED. In contrast, high-frequency use of ambulatory care (> or = 3 visits) was independently associated with having insurance (Medicare/Medicaid: AOR = 2.39; 95% CI = 1.31, 4.69), having HIV/AIDS (AOR = 3.15; 95% CI = 1.70, 5.85), and receiving substance abuse treatment during the study period (AOR = 3.58; 95% CI = 1.61, 7.98) Efforts to redirect medical care to more subacute settings will likely require both capacity building and addressing a client's underlying needs, including homelessness, access to substance abuse treatment, and chronic disease management.