Patterns in the use of benzodiazepines in British Columbia: Examining the impact of increasing research and guideline cautions against long-term use
Introduction
Primarily indicated for short periods of treatment for symptoms of anxiety and sleep disorders, benzodiazepines are one of the most commonly prescribed types of neurological drug in developed countries [1], [2], [3], [4], [5]. They are also not without controversy. Problems associated with long-term use of benzodiazepines are well documented—including, but not limited to, dependence and tolerance [6], cognitive impairment [7], and psychomotor impairment leading to increased risks of falls in the elderly [8]. As a result, many prescribing guidelines and research studies published over the past 20 years have cautioned against the use of benzodiazepines for extended periods [9], [10], [11], [12], [13], [14], [15], [16]. For example, in defining the indicators of inappropriate prescribing for seniors based on consultation with prescribers, both Canadian and American research teams included long-term prescribing of certain types of benzodiazepines in their priority lists [11], [12], [13], [14]. As well, the Canadian Compendium of Pharmaceutical Specialties, a cited resource for physicians in making therapeutic treatment decisions [17], contains recommendations for short-term and careful use of benzodiazepines and related benzodiazepine-receptor agonists [18].
Previous studies have documented significant rates of long-term benzodiazepine use, especially among the elderly [19]. Using data from several cycles of the Canadian National Population Health Surveys, Neutel found that nearly half of those reporting benzodiazepine use in one cycle reported use again in the following cycle [20], [21]. Using administrative data for those 65 and older in the Canadian province of Quebec, Bartlett et al. found the mean length of uninterrupted use of benzodiazepines for new benzodiazepine users in 1989 was 75.5 days [19]. Similarly, recent surveys in Europe have found half of users in 1 year were still using in the next [5], and that the duration of use was more than 6 months for 75.9% of benzodiazepine users [2]. However, these and other previous studies of long-term or repeated use of benzodiazepines have either been point-in-time assessments, have focused solely on use in senior populations, and/or have relied on survey data with limited reliability, ability to describe intensity or length of use, and statistical power [1], [19], [20], [21], [22], [23], [24], [25]. Using datasets from the province of British Columbia, Canada, we investigate patterns and predictors of benzodiazepine use and long-term use by persons of all ages, and describe how age-specific rates of use have changed over a 10-year period during which cautions about benzodiazepine use were widely disseminated. We aim to explore the effect on the prevalence of long-term use, if any, of the proliferation – in research, on product monographs, and in prescribing guidelines – of warnings against use of benzodiazepines for extended periods.
Section snippets
Materials and methods
We used data detailing prescription drug and medical services use, hospitalizations, demographics, and household income for virtually all residents of British Columbia (BC). De-identified data for the calendar years 1996 and 2006 were extracted and linked with permission from the BC Ministry of Health and the BC College of Pharmacists. This study was approved by the Behavioural Research Ethics Board at the University of British Columbia.
Use and long-term use in 2006
In 2006, approximately 4.9% of the BC population filled benzodiazepine prescriptions that did not exceed 100 days in total supply, and 3.5% filled benzodiazepine prescriptions exceeding 100 days in total supply. As shown in Table 1, women accounted for two out of every three BC residents who filled prescriptions for benzodiazepines in 2006—for short- or long-term use. Users of benzodiazepines were generally older than non-users: nearly half of all long-term users were over 65 and more than a
Discussion
Our study shows that despite years of research evidence and cautions around benzodiazepine use, rates of both use and long-term use have not appreciably changed between 1996 and 2006—in fact, rates have slightly increased, even after controlling for changes in the age, sex and health status of the population.
We found that benzodiazepines users in BC are, older, sicker (by a variety of health status measures), and are more likely to be female than non-users, on par previous findings regarding
Conclusions
While benzodiazepine use overall in BC during the period of our study did not increase as greatly as other therapeutic categories [3], the results of our study concerning patterns of use over time are not promising. Our findings suggest that research evidence and changes in prescribing guidelines have done little to change the potentially inappropriate way benzodiazepines have been and continue to be used by the population of BC. Long-term use of benzodiazepines fell slightly among the very
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