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Table 1.  Baseline Characteristics of SUSTAIN Enrollees With a Prescription for a Benzodiazepine and Those With Long-term Use, Percentage of Group, and Mean Scores
Baseline Characteristics of SUSTAIN Enrollees With a Prescription for a Benzodiazepine and Those With Long-term Use, Percentage of Group, and Mean Scores
Table 2.  Factors Associated With Benzodiazepine Medication Possession Ratio (MPR) Greater Than 30% During the 1 Year Following the Index Prescription
Factors Associated With Benzodiazepine Medication Possession Ratio (MPR) Greater Than 30% During the 1 Year Following the Index Prescription
1.
Olfson  M, King  M, Schoenbaum  M.  Benzodiazepine use in the United States.  JAMA Psychiatry. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763PubMedGoogle ScholarCrossref
2.
Gray  SL, Eggen  AE, Blough  D, Buchner  D, LaCroix  AZ.  Benzodiazepine use in older adults enrolled in a health maintenance organization.  Am J Geriatr Psychiatry. 2003;11(5):568-576. doi:10.1097/00019442-200309000-00012PubMedGoogle ScholarCrossref
3.
Simon  GE, Ludman  EJ.  Outcome of new benzodiazepine prescriptions to older adults in primary care.  Gen Hosp Psychiatry. 2006;28(5):374-378. doi:10.1016/j.genhosppsych.2006.05.008PubMedGoogle ScholarCrossref
4.
Mavandadi  S, Benson  A, DiFilippo  S, Streim  JE, Oslin  D.  A telephone-based program to provide symptom monitoring alone vs symptom monitoring plus care management for late-life depression and anxiety: a randomized clinical trial.  JAMA Psychiatry. 2015;72(12):1211-1218. doi:10.1001/jamapsychiatry.2015.2157PubMedGoogle ScholarCrossref
5.
Kurko  TA, Saastamoinen  LK, Tähkäpää  S,  et al.  Long-term use of benzodiazepines: definitions, prevalence and usage patterns—a systematic review of register-based studies.  Eur Psychiatry. 2015;30(8):1037-1047. doi:10.1016/j.eurpsy.2015.09.003PubMedGoogle ScholarCrossref
6.
Tannenbaum  C, Martin  P, Tamblyn  R, Benedetti  A, Ahmed  S.  Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.  JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949PubMedGoogle ScholarCrossref
Research Letter
Less Is More
November 2018

Factors Associated With Long-term Benzodiazepine Use Among Older Adults

Author Affiliations
  • 1Program for Positive Aging, Department of Psychiatry, University of Michigan Medical School, Ann Arbor
  • 2Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
  • 3Mental Illness Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 4Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Intern Med. 2018;178(11):1560-1562. doi:10.1001/jamainternmed.2018.2413

Benzodiazepine use among older adults is common despite evidence for many potential risks. While treatment guidelines recommend short-term use of benzodiazepines, up to one-third of use is long term, which is most common among older adults.1 To reduce benzodiazepine prescribing to older adults, one potential point for intervention is at the transition from new to long-term use, yet little is known about the factors that predict conversion to long-term use.2,3

Methods

We evaluated transition to long-term benzodiazepine use among older adults newly prescribed this drug (n = 576) by a nonpsychiatric clinician from 2008 to 2016 within Pennsylvania’s prescription assistance program for low-income older adults. Patients newly prescribed a benzodiazepine (ie, those with no use in the past year) were contacted for clinical assessment by a telephone-based behavioral health service (Supporting Seniors Receiving Treatment and Intervention [SUSTAIN]).4 The initial assessment included screening instruments assessing for depression, anxiety, sleep quality, and pain. Long-term benzodiazepine use was defined as a medication possession ratio (MPR) greater than 30% in the year following the initial prescription. Logistic regression was used to determine patient sociodemographic and clinical characteristics associated with long-term benzodiazepine use. After completing the clinical interview, participants provided verbal consent to allow the use of clinical data for research purposes in accordance with a University of Pennsylvania Institutional Review Board–approved protocol. Analyses were conducted using SAS statistical software, version 9.4 (SAS Institute Inc).

Results

The mean (SD) age of adults newly prescribed a benzodiazepine was 78.4 (7.0) years (Table 1). One year after the index prescription, 152 (26.4%) met the definition of long-term use; this group was prescribed a mean (SD) of 232.7 (82.6) benzodiazepine days. In adjusted analyses, white race (odds ratio [OR], 4.19; 95% CI, 1.51-11.59), days supplied in the index prescription (OR, 1.94; 95% CI, 1.52-2.47), and poor sleep quality (OR, 4.05; 95% CI, 1.44-11.43) were associated with increased long-term benzodiazepine use (Table 2). High anxiety and depression did not predict long-term benzodiazepine use in either unadjusted or adjusted analyses.

For sensitivity analyses, we completed adjusted models predicting 3 alternative long-term benzodiazepine use outcomes at 1 year, whether the patient (1) was prescribed at least 1 benzodiazepine refill (white race and days supplied were significant), (2) had a benzodiazepine prescription 1 year after index date (ie, on day 366; days supplied were significant); and (3) MPR as a continuous measure (white race and days supplied were significant).

Discussion

In this sample of older adults newly prescribed a benzodiazepine by a nonpsychiatric clinician, nearly one-third of patients went on to long-term use. While treatment guidelines recommend only short-term prescribing, if any, these long-term patients were prescribed nearly 8 months’ worth of benzodiazepine. Of the clinical measures evaluated, only poor sleep quality was associated with the likelihood of continued benzodiazepine use in adjusted analyses. White patient race and a larger initial prescription were also associated with conversion to long-term use. It is a cause for concern that these nonclinical factors are associated with benzodiazepine prescribing, which suggests that approaches to reduce prescribing of this drug that focus on specific clinical populations may have limited success.

Among our study’s limitations, it does not account for as-needed medication use, which may have an effect on our calculation of long-term use. The analysis is limited to low-income older adults from Pennsylvania, which may limit generalizability. Definitions of long-term benzodiazepine use vary,5 and it is possible that a different classification of long-term use might have yielded different results. However, we used 3 alternative definitions with no significant variation in our findings.

In conclusion, for new benzodiazepine users, prescribers should “begin with the end in mind” and immediately engage patients in discussion regarding the expected (brief) length of treatment, particularly when prescribed for insomnia. In light of the continued growth of psychotropic prescribing to older adults by nonpsychiatric clinicians, it is critical to improve access to and education regarding nonpharmacologic treatment so clinicians feel they have treatment alternatives to offer.6

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Article Information

Accepted for Publication: April 16, 2018.

Corresponding Author: Lauren B. Gerlach, DO, Program for Positive Aging, Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI 48109 (glauren@med.umich.edu).

Published Online: September 10, 2018. doi:10.1001/jamainternmed.2018.2413

Author Contributions: Dr Mavandadi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gerlach, Mavandadi, Oslin.

Acquisition, analysis, or interpretation of data: Gerlach, Maust, Leong, Mavandadi.

Drafting of the manuscript: Gerlach, Oslin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Leong, Mavandadi.

Obtained funding: Oslin.

Administrative, technical, or material support: Mavandadi, Oslin.

Study supervision: Gerlach, Oslin.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by the Pharmaceutical Assistance Contract for the Elderly of the Commonwealth of Pennsylvania.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Olfson  M, King  M, Schoenbaum  M.  Benzodiazepine use in the United States.  JAMA Psychiatry. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763PubMedGoogle ScholarCrossref
2.
Gray  SL, Eggen  AE, Blough  D, Buchner  D, LaCroix  AZ.  Benzodiazepine use in older adults enrolled in a health maintenance organization.  Am J Geriatr Psychiatry. 2003;11(5):568-576. doi:10.1097/00019442-200309000-00012PubMedGoogle ScholarCrossref
3.
Simon  GE, Ludman  EJ.  Outcome of new benzodiazepine prescriptions to older adults in primary care.  Gen Hosp Psychiatry. 2006;28(5):374-378. doi:10.1016/j.genhosppsych.2006.05.008PubMedGoogle ScholarCrossref
4.
Mavandadi  S, Benson  A, DiFilippo  S, Streim  JE, Oslin  D.  A telephone-based program to provide symptom monitoring alone vs symptom monitoring plus care management for late-life depression and anxiety: a randomized clinical trial.  JAMA Psychiatry. 2015;72(12):1211-1218. doi:10.1001/jamapsychiatry.2015.2157PubMedGoogle ScholarCrossref
5.
Kurko  TA, Saastamoinen  LK, Tähkäpää  S,  et al.  Long-term use of benzodiazepines: definitions, prevalence and usage patterns—a systematic review of register-based studies.  Eur Psychiatry. 2015;30(8):1037-1047. doi:10.1016/j.eurpsy.2015.09.003PubMedGoogle ScholarCrossref
6.
Tannenbaum  C, Martin  P, Tamblyn  R, Benedetti  A, Ahmed  S.  Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.  JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949PubMedGoogle ScholarCrossref
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