Zoorob Michael James
Department of Government, Harvard University, Cambridge, MA, USA.
Pharmacoepidemiol Drug Saf. 2018 May;27(5):541-549. doi: 10.1002/pds.4417. Epub 2018 Mar 14.
Although polydrug incidents comprise a substantial proportion of overdose deaths, scholarly and popular focus has centered on prescription opiates. This study examines the role of benzodiazepine and opioid prescriptions on overdose-both individually and synergistically-using data from Medicare Part D, a source of prescription drug claims for about 35 million Americans.
Prescribing data from the Medicare Part D Public Use Files for 2013, 2014, and 2015 (approximately 3.5 billion prescription drug claims) are geolocated using the prescriber's national provider identifier to calculate the proportion of claims for opioids and benzodiazepines in each county. These rates are matched with overdose data and controls to compile an analytic dataset of 9105 county-years. Multinomial logistic regression is used to estimate the probability that a county experiences higher rates of overdose fatalities.
A 1% increase in the benzodiazepine proportion of claims is associated with 1.2 odds of high, versus low, overdose (P < .1) and 1.4 odds of very high overdose (P < .05). Moreover, there was a substantial interaction between opioids and benzodiazepines (P < .001). A county with 6% benzodiazepine prescriptions and 12% opioid prescriptions has a .58 predicted probability of very high overdose, significantly higher (P < .001) than the .33 probability for a county with 12% opioid prescriptions but 3% benzodiazepine prescriptions.
These findings shed light on the polydrug epidemiology of the overdose epidemic. Overdose deaths are highest where elevated opioid and benzodiazepine claims coexist. Overdose levels may reflect polydrug use and misuse, requiring clinical and policy responses beyond reducing opioid prescriptions.
尽管多药滥用事件在过量用药死亡中占相当大的比例，但学术和大众关注的焦点一直集中在处方阿片类药物上。本研究利用医疗保险D部分的数据，研究苯二氮䓬类药物和阿片类药物处方在过量用药方面的作用——单独作用和协同作用，医疗保险D部分是约3500万美国人的处方药索赔来源。
使用开处方者的国家提供者标识符对2013年、2014年和2015年医疗保险D部分公共使用文件中的处方数据（约35亿份处方药索赔）进行地理位置定位，以计算每个县阿片类药物和苯二氮䓬类药物索赔的比例。这些比率与过量用药数据及对照进行匹配，以编制一个包含9105个县年的分析数据集。使用多项逻辑回归来估计一个县出现较高过量用药死亡率的概率。
苯二氮䓬类药物索赔比例增加1%，与低过量用药相比，高过量用药的几率为1.2（P < 0.1），与极低过量用药相比，极高过量用药几率为1.4（P < 0.05）。此外，阿片类药物和苯二氮䓬类药物之间存在显著的相互作用（P < 0.001）。一个县苯二氮䓬类药物处方占6%且阿片类药物处方占12%，其极高过量用药的预测概率为0.58，显著高于苯二氮䓬类药物处方占3%但阿片类药物处方占12%的县的0.33概率（P < 0.001）。
这些发现揭示了过量用药流行的多药流行病学情况。在阿片类药物和苯二氮䓬类药物索赔量升高同时存在的地方，过量用药死亡人数最高。过量用药水平可能反映了多药使用和滥用情况，这需要除减少阿片类药物处方之外的临床和政策应对措施。
