Under-treatment of pain is frequently reported, especially among seniors, with chronic non-cancer pain most likely to be under-treated. Legislation regarding the prescribing/dispensing of opioid analgesics (including multiple prescription programs [MPP]) may impede access to needed analgesics.
To describe access and intensity of use of analgesics among older Manitobans by health region.
A cross-sectional study of non-Aboriginal non-institutionalized Manitoba residents over 65 years of age during April 1, 2002 to March 31, 2003 was conducted using the Pharmaceutical Claims data and the Cancer Registry from the province of Manitoba. Access to analgesics (users/1000/Yr) and intensity of use (using defined daily dose [DDD] methodology) were calculated for non-opioid analgesics, opioids, and multiple-prescription-program opioids [MPP-opioids]. Usage was categorized by age, gender, and stratified by cancer diagnosis. Age-sex standardized rates of prevalence and intensity are reported for the eleven health regions of Manitoba.
Thirty-four percent of older Manitobans accessed analgesics during the study period. Female gender, increasing age, and a cancer diagnosis were associated with greater access and intensity of use of all classes of analgesics. Age-sex standardized access and intensity measures revealed the highest overall analgesic use in the most rural / remote regions of the province. However, these same regions had the lowest use of opioids, and MPP-opioids among residents lacking a cancer diagnosis.
This population-based study of analgesic use suggests that there may be variations in use of opioids and other analgesics depending on an urban or rural residence. The impact of programs such as the MPP program requires further study to describe its impact on analgesic use.
In September 1999, several Canadian provinces had place-of-sale restrictions lifted that had limited the sale of acetaminophen >325 mg and packages >24 tablets (any strength) to pharmacies only. This allowed the sale of all strengths of immediate-release acetaminophen in all package sizes in nonpharmacy locations. This study's purpose was to explore the effect that lifting restrictions on acetaminophen place of sale may have had on reported hospitalizations in Canada related to acetaminophen overdose toxicity. Using hospital discharge data, provinces with no preexisting restrictions on place of sale were compared with those in which restrictions were lifted in September 1999. Cases of reported APAP overdose included ICD-9/9-CM code 965.4, ICD-9 code E850.2, or ICD-9-CM code E850.4. Cases with reported acute liver toxicity included ICD-9/9-CM codes 570, 572.2, 572.4, V42.7, or procedure code 50.5. There were no significant differences between the 1.5-year periods pre- and post-September 1999 in annual incidence rates per 100,000 persons ages >/=12 years of hospitalizations reported with acetaminophen overdose, either overall or limited to those with death as an outcome, or in hospitalization reports with both acetaminophen overdose and acute liver toxicity, either overall (provinces with no restrictions: pre = 0.70, post = 0.80, P = 0.6328; provinces with restrictions lifted in September 1999: pre = 0.49, post = 0.47, P = 0.8649) or limited to those with death as an outcome (provinces with no restrictions: pre = 0.22, post = 0.12, P = 0.3030; provinces with restrictions lifted in September 1999: pre = 0.13, post = 0.09, P = 0.3589). In conclusion, the decision to lift Canadian place-of-sale restrictions increased acetaminophen availability and did not increase the rate of reported hospitalizations related to acetaminophen overdose toxicity.
Therapy for management of acute myocardial infarction (AMI) varies according to patient, prescriber and geographical characteristics.
To describe the in-hospital use of reperfusion therapy for ST elevation MI (STEMI) and discharge use of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and statins in patients presenting with either STEMI or non-STEMI in Canada from 1999 to 2002.
Four Canadian registries (FASTRAK II, Canadian Acute Coronary Syndromes, Enhanced Feedback for Effective Cardiac Treatment and Improving Cardiovascular Outcomes in Nova Scotia) were used to identify patients with AMI in Canada and to measure in-hospital reperfusion and medication use. Use rates were compared by age, sex, time period and geographical area, according to available data.
Use rates for reperfusion in STEMI patients ranged from 60% to 70%, primarily representing fibrinolytic therapy. A delay in presentation to hospital after symptom onset represented an impediment to timely therapy, which was particularly pronounced for women and elderly patients. Overall, less than 50% of patients met the door-to-needle target of less than 30 min. Medication use rates at discharge increased from 1999/2000 to 2000/2001 across the different data sources: acetylsalicylic acid, 83% to 88%; beta-blockers, 74% to 89%; ACEIs, 54% to 67%; statins, 41% to 53%; and calcium antagonists, 21% to 32%.
Canadian and provincial rates of use of evidence-based medications for the treatment of AMI have increased over time, although there remains room for improvement. A single, comprehensive data source would supply better insights into the management of AMI in Canada.
Conventional estimates of antidepressant (AD) utilization in major depressive syndrome (MDS) have been low, but this may be partially because ongoing AD use by individuals with resolved MDS is not included. Valid estimates of AD utilization should include this ongoing use for MDS, but this is difficult since most surveys do not collect data on the reason for taking ADs. Only a proportion (f(dep)) of the nondepressed (nMDS) population taking ADs does so for depression. Published studies have not reported this proportion, and data required to estimate f(dep) are not usually available from surveys. The current study was performed to (1) estimate f(dep) by employing information on past history of depression, and (2) use the estimate to obtain an "adjusted" AD utilization rate, including resolved MDS subjects taking ADs. Data were collected in Calgary in 1998 and 1999 by random-digit dial telephone interview from consenting adults aged 18+ years. MDS was assessed using the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD). Data were gathered on current medications, past depression, and current chronic physical illness. Of 2,542 respondents, 17.1% had MDS as defined by the CIDI-SFMD. A total of 20.2% of MDS and 3.2% of nMDS subjects were taking ADs. Of nMDS individuals taking ADs, 70.6% reported past depression (f(dep) = 70.6%). An "adjusted" AD utilization rate including this group was 28.2%. Physical illnesses that can be treated with ADs affected only 30.0% of nMDS subjects without past depression taking ADs. This study suggests that most individuals without active depression taking ADs do so for depression. AD utilization rates that ignore this group may be unrealistically low. AD use among nMDS subjects without previous depression is probably not primarily for physical illnesses. Limitations include the use of a brief predictive instrument for MDS, and self-report of past depression.
To examine if the suicide rate of older adults prescribed antidepressants varies with age and to assess the proportion of older adults who died by suicide that had recently been prescribed antidepressants.
A population-based cohort study using a nationwide linkage of individual-level records was conducted on all persons aged 50+ living in Denmark during 1996-2006 (1,215,524 men and 1,343,568 women). Suicide rates by treatment status were calculated using data on all antidepressant prescriptions redeemed at pharmacies.
Individual-level data covered 9,354,620 and 10,720,639 person-years for men and women, respectively. Men aged 50-59 who received antidepressants had a mean suicide rate of 185 (95% confidence interval [CI]: 160-211) per 100,000, whereas for those aged 80+ the rate was 119 (95% CI: 91-146). For women, the corresponding values were 82 (95% CI: 70-94) and 28 (95% CI: 20-35). Logistic regression showed a 2% and 3% decline in the rate for men and women, respectively, considered in treatment with antidepressants, with each additional year of age. An opposite trend was found for persons not in treatment. Fewer persons aged 80+ dying by suicide had received antidepressant prescriptions during the last months of life than younger persons.
An age-dependent decline in suicide rate for antidepressant recipients was identified. One reason could be that older adults respond better to antidepressants than younger age groups. Still, the increasing gap with age between estimated prevalence of depression and antidepressant prescription rate in persons dying by suicide underscores the need for assessment of depression in the oldest old.
Cites: J Am Geriatr Soc. 2000 Jan;48(1):23-910642017
Cites: Am J Psychiatry. 2000 Jul;157(7):1089-9410873916
Cites: J Public Health Med. 2001 Dec;23(4):262-711873886
Cites: Int Psychogeriatr. 2000 Jun;12(2):209-2010937541
Cites: Int J Geriatr Psychiatry. 2000 Aug;15(8):736-4310960886
In drug utilisation studies, the units of defined daily doses (DDD) and DDD/1000 inhabitants per day standardise for differences in dosage and population size, but not for age-related differences in drug utilisation. There is no consensus as to how age standardisation of DDD data should be carried out. Using cardiovascular drug utilisation data from Sweden and Spain, the current study compared the outcome of different methods of age standardisation. Both indirect methods (based on a comparison of observed and expected drug usage) and direct methods (using different weighting for the age categories) were used. The largest impact of standardisation was seen for diuretics. The crude rate for men and women combined was 26 DDD/1000 inhabitants per day in Costa de Ponent and 98 DDD/1000 inhabitants per day in Värmland. The corresponding figures when standardising the Costa de Ponent population were 26 and 58, respectively. Using the equivalent average rate (EAR) method, the rate for Värmland was 129 DDD/1000 inhabitants per day. Lesser but still important differences were found for beta-adrenoceptor and antihypertensives. Thus, the results of standardisation differ depending on which method is used and which drugs are evaluated. EAR is recommended for direct standardisation because of its ease of use and because it does not require the choice of a standard population.
To compare self-reported (SR) medication use and pharmacy data for major psychoactive medications and three classes of medications used for different indications, and to determine the socio-economic factors associated with the congruence.
Postal questionnaire data collected in 1997 were compared with the register of the Social Insurance Institution of Finland on the reimbursed prescriptions purchased during 1997. Altogether 7625 subjects were included in this study. Drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) system.
Kappa values were 0.77, 0.68, 0.84, 0.92 and 0.55 for antipsychotics, antidepressants, antiepileptics, antidiabetics and beta-blocking agents, respectively. Prevalence-adjusted and bias-adjusted kappa values were almost perfect (0.98-1.00). Reliability of antipsychotics use was better for married subjects than for those who were not married; and of antidepressants use for highly educated and married subjects than for those who were less educated and were not married. Altogether 414 (5.4%) responders and 285 (7.1%) non-responders had used at least one of the selected medications.
Agreement between the SR and pharmacy data was moderate for psychoactive medication use. Even though data collected by postal questionnaire may underestimate the prevalence of medication use due to non-participation it can be assumed accurate enough for study purposes.
To study the relations between postnatal maternal morbidity, child morbidity and welfare interventions in families with prenatal alcohol or substance abuse.
A register-based longitudinal retrospective cohort study. The exposed cohort included 638 children born to 524 women followed-up during pregnancy for alcohol or substance abuse 1992-2001. Non-exposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Perinatal and follow-up data of both cohorts were collected from national registers until 2007.
Postnatal maternal abuse-related healthcare utilization and use of medication were associated with child out-of-home care. Significant differences were in particular observed in the categories of maternal mental and behavioural disorders caused by psychoactive substance use as well as injury and poisoning. Maternal inpatient care for mental and behavioural disorders peaked at the time of child out-of-home care. Maternal abuse-related healthcare utilization was associated with early child healthcare utilization and use of medication for mental and behavioural disorders. These associations were largely explained by the association with child out-of-home care.
Postnatal maternal abuse-related morbidity is associated with significant early child morbidity, use of medication and timing of out-of-home care.
BACKGROUND: Chronic musculoskeletal complaints are common in the clinical setting and a therapeutic challenge. Little is known about the extent and type of pain-relieving drugs used by these patients in Norway. MATERIAL AND METHODS: 500 patients were referred for specialist evaluation because of chronic musculoskeletal pain, most of them from the National Insurance Administration. The diagnoses were grouped into four main categories. 95% of the patients had non-specific myofascial pain syndromes and about 5% had some form of osteoarthritis. In the majority the pain was chronic. All patients were asked which pain-relieving drugs they had taken during the previous week, prescribed drugs as well as over-the-counter drugs. Those taking non-steroidal anti-inflammatory drugs (NSAIDs) were also asked if these had been prescribed under the National Health Insurance scheme. RESULTS: 40% had completely abstained from analgesics. 32% had taken an NSAID; 20% a codeine-paracetamol compound; 15% paracetamol; 8% muscle-relaxants, while 26 patients had taken some other type of medication. About two thirds of the patients reported having received reimbursable NSAID-prescriptions, of which only about 9% were judged to qualify for this. INTERPRETATION: Even though a substantial number of patients had not taken pain-relieving drugs during the previous week, the number of patients having taken either NSAIDs, opioids or muscle relaxants was relatively high, both with regard to actual or potential side effects and to existing recommendations. The study also suggests that stricter application of the rules for reimbursement of drugs seems justified.