Nav: Home

Medicating distress: Risky sedative prescriptions for older adults vary widely

October 18, 2018

Despite years of warnings that older adults shouldn't take sedative drugs that put them at risk of injury and death, a new study reveals how many primary care doctors are still prescribing them, how often, and exactly where.

Mapped out county by county, the study shows wide variation in prescriptions of the drugs, called benzodiazepines. Some counties, especially in the Deep South and rural western states, had three times the level of sedative prescribing as others.

The study also highlights gaps at the level of individual prescribers: Some primary care providers prescribed sedatives more than six times more often than their peers. These high-intensity prescribers of drugs such as Xanax, Ativan and Valium also tended to be high-intensity prescribers of opioid painkillers.

The counties with the most intense sedative prescribing also tended to have lower incomes, less-educated populations, and higher suicide rates, the study finds. They also overlap with other maps showing high county-level opioid painkiller prescribing.

"Taken all together, our findings suggest that primary care providers may be prescribing benzodiazepines to medicate distress," says Donovan Maust, M.D., M.Sc., the geriatric psychiatrist from the University of Michigan who led the study. "And since these drugs increase major health risks, especially when taken with opioid painkillers, it's quite possible that benzodiazepine prescribing may contribute to the shortened life expectancies that others have observed in residents of these areas."

Published in the Journal of General Internal Medicine by a team from U-M Department of Psychiatry and the University of Pennsylvania, the study shows the power of data to highlight persistent inappropriate use of medications.

Prescribing totals

The study is based on data about all prescriptions written in 2015 by primary care providers for patients in the Medicare Part D prescription drug program. The researchers combined it with county-level health and socioeconomic data from the County Health Rankings project.

In the single year studied, the 122,054 primary care providers included in the study prescribed 728 million days' worth of benzodiazepines to their patients, at a cost of $200 million.

The states with the highest intensity of prescribing -- which the researchers defined as the proportion of all medication days prescribed that were of benzodiazepines--were Alabama, Tennessee, West Virginia, Florida and Louisiana, while Minnesota, Alaska, New York, Hawaii and South Dakota had the lowest.

Across all types of providers, primary care and otherwise, benzodiazepines accounted for 2.3 percent of all medication days prescribed to Part D participants by those providers that year.

Primary care doctors accounted for 62 percent of the total. In fact, the researchers focused on primary care providers specifically because previous studies had showed they account for the majority of benzodiazepines prescribed to older adults, who are much less likely than younger adults to see a psychiatrist.

Higher sedative prescription intensity was also associated at the county level with more days of poor mental health, a higher proportion of disability-eligible Medicare beneficiaries, and a higher suicide rate.

More about sedative risks

Benzodiazepines have often been prescribed to ease anxiety or insomnia, though several studies by Maust and others have shown that patients receiving the drugs often don't have a formal diagnosis of either condition.

But the drugs come with a price: clouded thinking ability, higher risk of auto accidents, falls and fractures, and a tendency to hook patients into long-term use despite their intended use as a short-term treatment. Benzodiazepines as a class are the second-most common group of drugs associated with medication-related overdose deaths, right behind opioid painkillers.

Such risks have landed benzodiazepines on the national guideline for prescription drugs that people over age 65 shouldn't take, though their short-term use in treating anxiety or insomnia that haven't responded to other options is still considered acceptable.

More about the study

To contribute to the county-level study, a given primary care provider had to prescribe a benzodiazepine at least 10 times in 2015. For the individual physician-level study, 109,700 doctors were studied, since the 10 percent of prescribers who saw the fewest Medicare beneficiaries were excluded.

The researchers divided individual prescribers into four groups according to the intensity level of their benzodiazepine prescribing.

The range was large - for the lowest group, about 0.6 percent of their total prescriptions were for benzodiazepines, compared with 3.9 percent of the highest-intensity group. That's a 6.5-fold difference in benzodiazepine prescribing.

Those in the highest-intensity group were also likely to be high-intensity prescribers for opioids and antibiotics, and also for other drugs that have been classed as high-risk for older adults.

"That the same providers appear to be high-intensity prescribers of both medications is potential cause for concern," says Maust.

Female primary care providers were less likely to be high-intensity benzodiazepine prescribers. The more years a physician had been in practice, the higher their chance of being a high-intensity prescriber.

Physicians with higher percentages of patients who were white, or who received the "Extra Help" payments available to low-income, low-resource patients under Part D of Medicare were also more likely to be high-intensity sedative prescribers.

The researchers could not see data down to the patient-level in the available Medicare data, so they couldn't look at what conditions patients were listed as having, other clinical findings, or the patients' individual social and economic status.
-end-
In addition to Maust, the research team included senior author Steven Marcus, Ph.D. of the University of Pennsylvania, and U-M Department of Psychiatry faculty L. Allison Lin, M.D., M.Sc. and Fred Blow, Ph.D. Maust, Lin and Blow are all members of the U-M Institute for Healthcare Policy and Innovation.

Funding for the work came from National Institutes of Health (AG048321, DA045705), the American Federation for Aging Research, the John A. Hartford Foundation, and the Atlantic Philanthropies.

Michigan Medicine - University of Michigan

Related Primary Care Articles:

The need to reinvent primary care
Primary care is 'first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system.' High-quality primary care has been associated with improved population health, lower costs, and greater equity.
Affordable Care Act boosted primary care access for Medicaid patients
Since the introduction of the Affordable Care Act, which provided access to health insurance to millions of previously uninsured adults in the United States, the availability of appointments with primary care physicians has improved for patients with Medicaid and remains unchanged for patients with private coverage, according to new research.
Gauging ACA's effect on primary care access
A new research letter published online by JAMA Internal Medicine assessed the Affordable Care Act's effect on primary care access because millions of uninsured adults have gotten health insurance since major coverage provisions were implemented.
What primary care providers should know about diabetic neuropathy
Researchers at Michigan Medicine led a group of internationally recognized endocrinologists and neurologists from both sides of the Atlantic and teamed up with the American Diabetes Association to craft a new position statement on the prevention, treatment and management of diabetic neuropathy.
Most primary care doctors 'strongly endorse' key elements of the Affordable Care Act
Proponents of repealing the Affordable Care Act, including President Donald Trump's nominee for Secretary of Health and Human Services, Tom Price, have argued that the law places an undue burden on physicians.
Primary care physician involvement at end of life associated with less costly, less intensive care
A new study published in the January/February issue of Annals of Family Medicine finds that primary care physician involvement at the end of life is associated with less costly and less intensive end-of-life care.
Patients not attached to new primary care practices receive lower quality care
One in six patients in Ontario does not belong to an organized primary care practice, new research suggests.
Having primary care physician may not be enough to reduce ED visits by vulnerable groups
Having a regular family physician may not be enough to reduce emergency department visits among patients with disabilities, a small study published in Canadian Family Physician suggests.
Primary care physicians primed to help patients be more active
Exercise plays a crucial role in being healthy and preventing disease.
Primary care is point of entry for many kids with concussions
Many children with concussion initially sought care through primary care and not the emergency department, although younger children and those insured by Medicaid were more likely to go to the ED, according to an article published online by JAMA Pediatrics.

Related Primary Care Reading:

Best Science Podcasts 2019

We have hand picked the best science podcasts for 2019. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Jumpstarting Creativity
Our greatest breakthroughs and triumphs have one thing in common: creativity. But how do you ignite it? And how do you rekindle it? This hour, TED speakers explore ideas on jumpstarting creativity. Guests include economist Tim Harford, producer Helen Marriage, artificial intelligence researcher Steve Engels, and behavioral scientist Marily Oppezzo.
Now Playing: Science for the People

#524 The Human Network
What does a network of humans look like and how does it work? How does information spread? How do decisions and opinions spread? What gets distorted as it moves through the network and why? This week we dig into the ins and outs of human networks with Matthew Jackson, Professor of Economics at Stanford University and author of the book "The Human Network: How Your Social Position Determines Your Power, Beliefs, and Behaviours".