Osteoporosis prevention among chronic glucocorticoid users: results from a public health insurance database.

INTRODUCTION: Long-term glucocorticoid therapy is the leading cause of secondary osteoporosis. The management of glucocorticoid-induced osteoporosis (GIOP) seems to be inadequate in many European countries. OBJECTIVE: To evaluate the rate of screening and treatment of GIOP. DESIGN: Information was collected from a national public health-insurance database in our geographic area of Provence-Alpes-Côte-d'Azur and in Corsica, from September 2009 through August 2011. PATIENTS: We identified participants aged 15 years and over starting glucocorticoid therapy (≥7.5 mg of prednisone equivalent per day during at least 90 days consecutive). This cohort was compared with an age-matched and sex-matched population that did not receive glucocorticoids. MAIN OUTCOME MEASURES: Bone mass, prescription of bone antiresorptive medication and use of calcium and/or vitamin D treatment. RESULTS: We identified 32 812 patients who were prescribed glucocorticoid therapy, yielding 1% prevalence. Incidence of glucocorticoid therapy was 2.8/1000 inhabitants/year. Males represented 44%, the mean age was 58 years. The median prednisone-equivalent dose was 11 mg/day (IQR 9-18 mg/day). 8% underwent bone mass measurement. Calcium and/or vitamin D, and bisphosphonates were prescribed in 18% and 12%, respectively. Results were lower for the control population: 3% underwent bone mass measurement and 3% received bisphosphonate therapy. The rates of osteodensitometry and treatments were higher in women over 55 years of age than in men and women 55 years of age and younger, and also when glucocorticoid therapy was initiated by a rheumatologist versus other physician specialty. CONCLUSIONS: The management of GIOP remains very inadequate, despite the availability of a statutory health insurance system. Targeted interventions are needed to improve the management of GIOP.

Patterns of methylphenidate use and assessment of its abuse and diversion in two French administrative areas using a proxy of deviant behaviour determined from a reimbursement database: main trends from 2005 to 2008.

BACKGROUND: Methylphenidate is a psychostimulant drug indicated for the treatment of attention-deficit hyperactivity disorder (ADHD). Its abuse and diversion have been previously described in specific populations, such as students; however, few studies investigating abuse and diversion among the overall population are available. OBJECTIVES: The aim of this study was to describe patterns of methylphenidate use and to explore the magnitude of its abuse and diversion in two French administrative areas using data from a reimbursement database. A proxy of 'deviant behaviour' was used for the abuse and diversion of methylphenidate, defined using the following parameters: total number of defined daily doses (DDDs) of methylphenidate dispensed; number of different pharmacies seen for dispensing of methylphenidate; number of prescribers consulted for a prescription of methylphenidate; and number of dispensings of methylphenidate. Data from the reimbursement database were analysed by clustering methods. These data were assessed from 2005 to 2008. METHOD: The French General Health Insurance System (GHIS) database was used to obtain data on methylphenidate use in two French administrative areas. Individuals affiliated to the GHIS who had a prescription for methylphenidate reimbursed between 1 January and 31 March of 4 selected years (2005, 2006, 2007 and 2008) were included. After the first dispensing of methylphenidate for these individuals, all their dispensings (including methylphenidate and other psychoactive drugs) were monitored over a 9-month period. Following a descriptive analysis, a clustering method was used to identify different subgroups of subjects according to the methylphenidate consumer profile characteristics. RESULTS: With regard to the number of patients who had a dispensing for methylphenidate during the first quarter of the year, an 84% increase was observed between 2005 (n = 640) and 2008 (n = 1175). The clustering method identified two subgroups. One of them was characterized by a higher number of dispensings, different prescribers and pharmacies and a greater total dispensed quantity, suggesting a deviant behaviour and, thus, possible abuse and diversion of methylphenidate. These subjects were older (aged 35.4 ± 11.3 years) and were more frequently patients receiving benzodiazepines, antidepressants, antipsychotics and maintenance opioid treatment. The proportion of subjects with a deviant behaviour increased from 0.5% in 2005 to 2% in 2007 and then decreased to 1.2% in 2008. CONCLUSION: This method was able to assess the magnitude of methylphenidate abuse liability and to follow its evolution. The decrease in methylphenidate abuse and diversion seen between 2007 and 2008 can be explained by the enactment in April 2008 of specific regulations for prescription drugs (such as methylphenidate) that are deemed by the French government to have the potential for misuse; these regulations require the establishment of a 'contract of care' between the GHIS, prescriber and patient.

Which indicators can public health authorities use to monitor prescription drug abuse and evaluate the impact of regulatory measures? Controlling High Dosage Buprenorphine abuse.

BACKGROUND: Two methods have been recently developed from a drug reimbursement database to provide useful indicators for public health authorities concerning the abuse potential of psychotropic drugs. The doctor-shopping indicator (DSI) measures the proportion of the drug obtained by doctor shopping among the overall quantity of the drug reimbursed and the clustering method reveals subgroups of deviant patients. OBJECTIVE: The objective of the study was to analyze and compare indicators resulting from these two methods, applied to High Dosage Buprenorphine (HDB) (a product well-known to be diverted in France), in order to determine which public health authorities needs they answer. DATA ANALYSIS: The patients with reimbursed HDB were grouped using the clustering method in terms of drug dispensations characteristics over a nine month period. The characteristics of the resulting subgroups, including their DSI, were then compared. RESULTS: 4787 Patients (73.4%) had no measurable doctor-shopping behaviour. But the comparison of the two methods demonstrated that the more a patient's profile was characterized by deviant behavior, the higher was the DSI: from 0.4% in a subgroup with a median profile to 72% in a subgroup with a deviant profile. CONCLUSION: These two methods are useful surveillance tools for public health authorities: the clustering method may help devise pertinent intervention strategies to reduce prescription drug abuse while the DSI method provides quantitative information demonstrating whether these strategies are useful. We discuss the advantages and disadvantages of using these two methods as useful indicators for public health authorities.

Estimation of clonazepam abuse liability: a new method using a reimbursed drug database.

Some observations suggest the existence of clonazepam abuse. The aim of this study was to assess its magnitude in real life by a new method, using a prescription database, and to assess its evolution between 2001 and 2006. Individuals from a region affiliated to the French health reimbursement system, who had a prescription of clonazepam reimbursed between 1 January and 15 February of two selected years were included. Their deliveries were monitored over a 9-month period. After a descriptive analysis, a clustering method illustrated by a factorial analysis was used to identify different subgroups of clonazepam consumers. An increase of 82% in participants who had a delivery of clonazepam between 2001 and 2006 was observed. Using the clustering method, this study identified some deviant participants. This group comprises a higher proportion of males, benzodiazepine users, and buprenorphine users. The number of deliveries by different prescribers and pharmacies are higher. The proportion of deviant participants increased between 2001 and 2006 (from 0.86 to 1.38%). Our method can be used to assess the magnitude of abuse liability of clonazepam and is also interesting for following its evolution, two important keys for assessing patterns of abuse.