69
Deprescribing by Policy David Gardner Cara Tannenbaum Justin Turner Andrea Murphy Kathleen Coleman Patricia Caetano
Deprescribing by Policy
David Gardner
Cara Tannenbaum
Justin Turner
Andrea Murphy
Kathleen Coleman
Patricia Caetano
Disclosure
Each presenter declares that they have
no actual or potential conflict of interest
in relation to this topic or presentation.
Acknowledgements
Jay Shaw
Dara Gordon
Zachery Bouck
James Silvius
3
Plan of the Panel
Cara Tannenbaum
CaDeN, Canada, sedative-hypnotics, and policies
Justin Turner International scan of policies to reduce BZRA use
Andrea Murphy
Analysis of policy context, mechanisms, and behaviour change techniques
Kathleen Coleman
Commentary: NS policies to reduce S-H use
Trish Caetano Commentary: MB policies to reduce S-H use
4
5
Review Article
The intended and unintended consequences of benzodiazepine
monitoring programmes: a review of the literature
J. Fisher* PhD, C. Sanyal* MSc, D. Frail‡ BSc(Pharm) MSc and I. Sketris* PharmD
*College of Pharmacy, Dalhousie University, Halifax, NS,
‡ Pharmaceutical Services, Nova Scotia Department of Health and Wellness
6
New York Times
“… prescribers could
be encouraged or required to
check their state’s prescription
drug monitoring program …
education on safe prescribing
should also include
information on
benzodiazepines”
2012: 38 benzodiazepine
prescriptions per 100 people
ISLAGIATT
Humphries. NEJM Feb 22, 2018
1. I have a connective tissue disease.
For some reason my specialist seemed to be pushing me to take a sleeping pill even when I told him I wasn’t interested. I walked out with a prescription and never filled it.
2. I used regular sleeping pills for a
while. When they didn’t work I was put on amitriptyline. Within two months I was hospitalized for a blockage in my colon.
5. My wife has been on sleeping pills
for > 10 years. When I mentioned I had a bit of sleep troubles to my doctor he prescribed zopiclone for 60 days. It was my first prescription. I didn’t take it.
6. She was an avid gardener. We saw
her in the Emerg after starting lorazaepam. She’d had a bad fall, taking large amounts of skin off her nose, lips, and chin, and her hands were a mess also.
3. My mother is frail. She feels really
unsteady when she takes them. She’s scared to leave her home.
8. Oh, I’m sleeping about the same. I
still wake in the middle of the night.
7. He’s been taking benzos for 2
decades and speaks about how wonderful they are. He has no interest in stopping them. I’m worried. He is not a safe driver.
4. A psychiatrist put me on it for panic
attacks 25 years ago. 10 years ago it took me 2 years to wean myself off. I still feel the effects.
Cara Tannenbaum, MD
Co-chair, Canadian Deprescribing Network
Professor, Faculties of Medicine and Pharmacy
Université de Montréal
8
The Canadian Deprescribing Network
Established in 2016
Our vision:
A Canada where all seniors use safe and appropriate drug and non-drug
therapies.
Our goals:
• Raise awareness and decrease the use of inappropriate medications for seniors
by 50% by 2020.
• Ensure access to safer drug and non-drug therapies.
Public awarenessHealth care provider
education
Policy decision-
making
Our strategies:
Proportion of seniors who are
chronic users of benzodiazepines
Source: Canadian Institute for Health Information
*Self report (Qc.)
Harmful effects of benzos
Memory impairment Falls
Fractures Automobile accidents
International policy attempts to
reduce sedative-hypnotic use
among seniors
• Prescriber monitoring
• Driver’s license restriction
• Medication scheduling change
• Regional educational campaign on non-
drug alternatives
• Financial incentivization to prescribers
• Removal of coverage
Which policies were effective?
Which policies were effective?
Which of these policies should
we apply in Canada?
Why not all?
Justin Turner, PhD, MClinPharm
Senior Advisor, Science Strategy for the Canadian
Deprescribing Network
Researcher, Institut universitaire de gériatrie de
Montréal
16
Financial incentivization
Rat C, et al. Did the new French pay-for-performance system modify benzodiazepine prescribing practices? BMC Health Serv Res. 2014;14:301.
Financial incentivization
1.4% new prescriptions overall
4.3% treatment >12 weeks
What happened?
Context
• Part of a Quality improvement
program
– 4 priorities: practice organization,
chronic disease management,
prevention, prescribing
– Total incentive payment of €5000
(€490 for prescribing component)
Removal of Coverage
Chen H et al. The impact of Medicare Part D on psychotropic utilization and financial burden for community-based seniors. Psychiatr Serv. 2008;59(10):1191-7.
Removal of Coverage
Chen H et al. Psychiatr Serv. 2008;59(10):1191-7.
5%, briefly
What happened?
Context
• Medicare Part D is for low income who
can’t afford insurance
• No implementation strategy
• No dose tapering strategy
22
Beware of unintended consequences
Medicare Part D Consequences
• out of pocket
expenses
• substitution to
other sedatives
• nursing home hip
fractures doubled
24
Briesacher BA, et al. Medicare part D's exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med. 2010;170(8):693-8
Public Education
Dollman WB, et al. Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach. J Clin Pharm Ther. 2005;30(5):425-32.
Public Education
19.1%What happened?
Context
• Regional area
• Motivated multidisciplinary team
• Local opinion leaders and peer champions
engaged
27
Thinking outside the box!
• Sometimes effective policy requires
Canadian seniors drivers license
29Published 9th April 2018
• BC: Mandatory test at 80yrs, +2yrs
• AL: 75+ = medical test at every license
renewal
• ON: 80+ medical test
• QC: 75yrs = physician report and at
80yrs, +2yrs
• Could we copy Denmark here?
Danish Drivers Licence
• Rules for renewal of drivers’ licences
Danish Drivers Licence
54% long
acting
35% short
acting
Between
2007-2013
What happened?
Context
• 2003: benzodiazepine reduction a priority
• 2003: several interventions implemented
32
• 2007; Introduction of
“Driving Under the
Influence of Drugs”
legislation
Medication Rescheduling
2
Schaffer AL, et al,. JAMA Intern Med 2016;176:1223-5
Rescheduling of Alprazolam
2
Schaffer AL et al JAMA Int Med 2016;176(8):1223
28% for
65-79
yrs old
39% for
80+
yrs old
What happened?
Context
• Alprazolam was already a restricted
benefit for panic disorder
• Alprazolam diversion was high
35
Consequences?
• 22% in overall alprazolam prescribing
• 50% in poison center calls
BUT, at what cost?
• street price
• benzodiazepines by 216%
• Overdose deaths involving 1 or more benzodiazepines from 42.2% to 52.5% (2009 – 2015)
2
Schaffer AL et al JAMA Int Med 2016;176(8):1223Lloyd B et al Int J Drug Pol 2017;39:138
Prescriber Monitoring
• Triplicate Prescription Program implementation
Wagner AK, et al. Int J Qual
Health Care. 2003;15(5):423-31.
McNutt LA, et al. J Clin
Epidemiol 1994;47:613-25
New York Triplicate Prescription
Program – Community level
40
35% overall
What happened?
New York Triplicate Prescription
Program – Hospital discharge
• Triplicate Prescription Program
implementation
53%♀
58%♂
Proportion of patients with new benzodiazepine prescription on hospital discharge
What happened?
Context
43
Context
• 1989: Pre “Beers List of inappropriate
medications”
• Change included: Maximum 30 days
supply, no refills
• Physicians had to order and pay for
serialised prescription pads
44
Unintended consequences
• Greatest Benzodiazepine reduction for
– Younger
– Black
– Urban-dwelling people with low income
• Patients with chronic psychiatric and
neurological disorders affected
• Switching was profound
45
Which policies for Canada?
• Political will is key
• Context is important
• But, how do we determine
what works?
for who?
and why?
46
Andrea Murphy, BSc Pharm, ACPR, PharmD
Executive Member, Canadian Deprescribing Network
Associate Professor, College of Pharmacy
Dalhousie University
47
Why do some
policies succeed
and others fail?
48
ISLAGIATT
it seemed like a good idea at the time
Complexity
“A complex adaptive system is a collection of individual agents with
freedom to act in ways that are not always totally predictable, and
whose actions are interconnected so that one agent's actions
changes the context for other agents.”
“Complex systems typically have fuzzy boundaries. Membership
can change, and agents can simultaneously be members of
several systems. This can complicate problem solving and lead to
unexpected actions in response to change.”
“Systems are embedded within other systems and co-evolve.”
49The challenge of complexity in health careBMJ 2001;323:625 Plsek PE, Greenhalgh T
Complexity
50
FIGURE 2-1
Conceptual drawing of a four-
level health care system.
From: 2, A Framework for a Systems Approach to Health
Care Delivery
Building a Better Delivery System: A New
Engineering/Health Care Partnership.
National Academy of Engineering (US) and Institute of
Medicine (US) Committee on Engineering and the Health
Care System; Reid PP, Compton WD, Grossman JH, et
al., editors. Washington (DC): National Academies Press
(US); 2005.
Reducing sedative-hypnotics
What works?
Versus
What tends to work,
for whom, in what
circumstances?
51
Rapid realist review
Focuses on program theories
• Explores C-M-O configurations
52
C
Context
M
Mechanisms
O
Outcomes
Saul JE, et al. A time-responsive tool for informing policy making: rapid realist review. Implementation Science20138:103https://doi.org/10.1186/1748-5908-8-103
Rapid realist review
• An intervention (I) triggers particular
mechanisms (M) of change.
– mechanisms work either wholly or largely through
the perceptions, reasoning, and actions of human
actors.
53
Rapid realist review
• Mechanisms may be more or less
effective in producing their intended
outcomes (O), depending on their
interaction with various contextual (C)
factors.
54
Rapid realist review
People’s responses are
supported or constrained by the
social, organizational, and
political circumstances in which
interventions are implemented
(context).
55
56
Greenhalgh J, Dalkin S, Gooding K, Gibbons E, Wright J, Meads D,et al.
Functionality andfeedback: a realist synthesis of the collation,
interpretation and utilisation of patient-reportedoutcome measures data to improve patient care.Health Serv Deliv Res2017;5(2).
Mechanisms
• Behaviour change theory
57
Michie et al. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. http://www.implementationscience.com/content/pdf/1748-5908-6-42.pdf
A framework of behaviour
6:42 doi:10.1186/1748-5908-6-42
COM-B
COM-B component TDF domain
Capability Psychological Knowledge
Skills
Memory, Attention and Decision Processes
Behavioural regulation
Physical Skills
Opportunity Social Social influences
Physical Environmental Context and Resources
Motivation Reflective Social/Professional Role and Identity
Beliefs about Capabilities
Optimism
Beliefs about Consequences
Intentions
Goals
Automatic Social/professional Role and Identity
Optimism
Reinforcement
Emotion
Can
e et al. http
://ww
w.im
plem
entatio
nscien
ce.com
/con
tent/7
/1/3
7
Theoretical Domain
1 Knowledge An awareness of the existence of something.
2 Skills An ability or proficiency acquired through practice.
3 Social/Professional Role
and Identity
A coherent set of behaviours and displayed personal qualities of
an individual in a social or work setting.
4 Beliefs about Capabilities Acceptance of the truth, reality, or validity about an ability,
talent, or facility that a person can put to constructive use.
5 Optimism The confidence that things will happen for the best or that
desired goals will be attained.
6 Beliefs about Consequences Acceptance of the truth, reality, or validity about outcomes of a
behaviour in a given situation.
7 Reinforcement Increasing the probability of a response by arranging a
dependent relationship, or contingency, between the response
and a given stimulus.
8 Intentions A conscious decision to perform a behaviour or a resolve to act in
a certain way.
Theoretical Domains Framework
Cane et al. Implementation Science 2012, 7:37 http://www.implementationscience.com/content/7/1/37
Theoretical Domain
9 Goals Mental representations of outcomes or end states that an individual
wants to achieve.
10 Memory, Attention &
Decision Processes
The ability to retain information, focus selectively on aspects
of the environment and choose between two or more alternatives.
11 Environmental Context
& Resources
Any circumstance of a person's situation or environment that
discourages or encourages the development of skills and
abilities, independence, social competence, and adaptive behaviour.
12 Social influences Those interpersonal processes that can cause individuals to change their
thoughts, feelings, or behaviours.
13 Emotion A complex reaction pattern, involving experiential, behavioural,
and physiological elements, by which the individual attempts to deal
with a personally significant matter or event.
14 Behavioural Regulation Anything aimed at managing or changing objectively observed or
measured actions.
Cane et al. Implementation Science 2012, 7:37 http://www.implementationscience.com/content/7/1/37
Theoretical Domains Framework
All definitions are based on definitions from the American Psychological Associations’ Dictionary of Psychology from Cane’s ref #36
Prescriber Monitoring
• Triplicate Prescription Program implementation
Wagner AK, et al. Int J Qual
Health Care. 2003;15(5):423-31.
McNutt LA, et al. J Clin
Epidemiol 1994;47:613-25
NY state TPP
C-M-O
Intervention Context
Benzodiazepine prescription control (TPP) with monitoring (external assessment)
NYS TPP
30 day supply
No repeats (excluding panic disorder, epilepsy)
1989
New York state
Era of consistent marketing of BZDs for neuroses
Liberal prescribing of BZDs is a normative prescribing behaviour.
Government official, “BZDs are a major public health danger”
Patient user fees: medical visits; prescriptions
TPP administrative burden to physician – ordering and paying for TPP pads
64
NY state TPP
C-M-OIntervention Mechanisms
Benzodiazepine prescription control (TPP) with monitoring (external assessment)
NYS TPP
30 day supply
No repeats (excluding panic disorder, epilepsy)
MD believes policy improves relationships with patients and reduces patient harms
MD unwilling to lose prescribing autonomy through monitoring
MD does not want to be identified as a high BZD prescriber
Patient concerned of negative health consequences of BZDs
Patient not willing to take a medication requiring a special prescription reserved for abused and addictive drugs
Patient cannot afford (time and out of pocket expenses) increased MD visits and prescriptions
65
NY state TPP
C-M-OIntervention Outcomes
Benzodiazepine prescription control (TPP) with monitoring (external assessment)
NYS TPP
30 day supply
No repeats (excluding panic disorder, epilepsy)
Reduced benzodiazepine use
Reduced benzodiazepines overdoses
No change in use of effective, safer alternatives
Increased use of other non-monitored sedative-hypnotics
Increased non-benzodiazepine overdose (higher mortality)
No change in hip fracture rate
66
CBT
NY state TPP
COM-BIntervention
Benzodiazepine prescription control (TPP) with monitoring (external assessment)
NYS TPP
30 day supply
No repeats (excluding panic disorder, epilepsy)
67
NY state TPP
COM-BIntervention
Benzodiazepine prescription control (TPP) with monitoring (external assessment)
NYS TPP
30 day supply
No repeats (excluding panic disorder, epilepsy)
68
COM-B TDF domain 🎯
C Psychological Knowledge 🎯
Memory, Attention and Decision Processes 🎯
Behavioural regulation 🎯
O Social Social influences 🎯
Physical Environmental Context and Resources 🎯
M Reflective Social/Professional Role and Identity 🎯
Optimism 🎯
Beliefs about Consequences 🎯
Automatic Social/professional Role and Identity 🎯
Optimism 🎯
Reinforcement 🎯
Emotion 🎯
Kathleen
Coleman
Director of Formulary and
Clinical Practice, Department
of Health & Wellness,
Government of Nova Scotia
69
CommentariesOverview of challenges of policy development in reducing sedative-hypnotics.
Patricia
Caetano
Executive Director, Provincial
Drug Programs, Government of
Manitoba
Chair, Drug Policy Advisory
Committee (DPAC) Optimal Use
Working Group, CADTH
Stakeholders
70
Research
Knowledge translation
MD, RN, RPh, Therapist,
others
Academia
Health Providers
Seniors
Mental health
Addictions
Community
Policy
Legislation
Regulations
Government
Seniors, Health,
Indigenous, Public Safety,
Transport
Police
Justice
College of Physicians &
Surgeons
College of Pharmacy
Regulators
P/F advocacy orgs
MD, RPh, RN, Therapists
Professional/ business
Policies to reduce use of
sedative-hypnotics
Care centres, authorities, and systems
Health Authorities
Deprescribing by Policy
Discussion
71
Thank YouPlease visit the CaDeN booth
Ballroom B1
72
