Pill Heads: Governance, Normalization & Risk in Prescription Drug Use
A copy of the conference proceedings is attached. The paper starts on page 61.
This paper will critically engage the discourses currently informing non-medical use and abuse of, and ‘addiction’ to... more This paper will critically engage the discourses currently informing non-medical use and abuse of, and ‘addiction’ to prescription drugs. As part of the analysis of non-medical prescription drug use the article draws from journalist and prescription painkiller addict Joshua Lyon’s successful 2008 autobiographical book, Pill Head. In particular, it will focus on the growing cultural assumption that an ever-increasing number of afflictions are pharmacologically treatable. This assumption sits behind the general normalization of taking pills, in opposition to the deep stigmatization of chemically similar illegal substances. However, there is new concern about this collective practice of non-prescribed pill-taking. This is a practice which has paradoxically been in part fostered by the pharmaceutical industry and the professional interests that it now appears to threaten. Furthermore, mental illness and addiction discourse ignores the individual agency of those who choose to take medications outside of conventional medical treatment. The paper discusses aspects of user risk-taking and the apparent clash between the practice of chosen pill taking and the deterministic official construction of the non-medical drug using subject.
Download (.pdf) (Pharmaco)Epidemiological characterization of type 2 diabetes in Portugal
PhD Thesis, Lisboa 2011
RESUMO
A prevalência de diabetes tipo 2 diagnosticada em Portugal é de 6.6%, tendo-se vindo a registar um... more
RESUMO
A prevalência de diabetes tipo 2 diagnosticada em Portugal é de 6.6%, tendo-se vindo a registar um aumento da despesa em saúde com a pessoa com diabetes. Sendo a gestão da diabetes, complexa e multifactorial, urge melhorar o conhecimento da situação nacional no que concerne à abordagem da pessoa com diabetes, com vista a
minimizar recursos e maximizar resultados.
Este trabalho teve por objectivo caracterizar a dimensão (farmaco)epidemiológica da diabetes tipo 2, em Portugal, através de:
I. Caracterização do consumo de antidiabéticos na última década, por análise de base de dados de consumo nacional e de estudos de utilização de medicamentos (2003/04 (n=1090) e 2008/09 (n=806)). Destaca-se a diminuição de consumo de sulfonilureias
(SUs) e aumento de biguanidas, em linha com as guidelines. Mais de metade dos doentes estavam tratados com politerapia de ADOs.
II. Caracterização da percepção da prestação de cuidados de saúde, ao diabético tipo 2 (2003/04 vs. 2008/09), avaliando-se: variáveis clínicas, educação para controlo da
doença, auto-vigilância, posse do ‘Guia da Pessoa com Diabetes’, avaliação da realização de exame aos olhos, exame aos pés e vacinação antigripal. Verificou-se que mais de 2/3 dos doentes faziam auto-vigilância, cerca de 1/3 não tinham efectuado exame aos olhos no ano anterior e aproximadamente 70% não tinha feito
exame aos pés. Só cerca de 50% receberam vacina antigripal.
III. Diferentes abordagens metodológicas para estimar a prevalência de DM2, diagnosticada e não disgnosticada. (1) Estimativa indirecta da prevalência de diabetes tipo 2, com base no consumo de ADOs (2000 a 2009), corrigindo para politerapia e não adesão à terapêutica. Em 2009, a prevalência estimou-se entre 5.06-7.05%, o que sugere que esta técnica pode vir a ser usada como estratégia de monitorização da prevalência. (2) Identificação de escalas para detecção de pessoas com diabetes tipo 2 não diagnosticada. A estratégia de busca recuperou 136 resumos que conduziram à inclusão de dez artigos na revisão sistemática de literatura efectuada.
Palavras-chave: diabetes mellitus tipo 2, consumo de medicamentos, DHD, estudo de utilização de medicamentos, estimativa prevalência, revisão sistemática de literatura, cuidados ao diabético.
ABSTRACT
The prevalence of type 2 Diabetes in Portugal is 6.6% and we are witnessing a rise of health expenditures with diabetic patients. Diabetic patients’ management is complex and multifaceted. It is urgent to increase our knowledge about the current situation of
care delivery to the the diabetic patient in Portugal, in order to minimize costs and obtain maximal beneficts in health outcomes.
Utilizing different methods and distinct methodological approaches, our goal was to improve the knowledge of the (pharmaco)epidemiology of type 2 diabetes in Portugal.
This report is divided into three main chapters as follows: I. The analysis of the consumption of hypoglycemic agents over the last decade, by means of drug consumption data base analysis and field drug use studies. The main findings were a decrease in the consumption of sulphonylureas alongside a rise of biguanides, in accordance with guidelines. More than half of the patients were treated with 2 or more oral hypoglycaemic agents (OHAs).
II. The self-reported provision of health care to patients with type 2 diabetes including information concerning: disease-related variables, education for disease control, selfmonitoring of blood glucose, having the “Guide for the Person with Diabetes”, assessment of diabetic retinopathy examination, foot examination, and flu vaccination.
It has been found that 68.3% patients performed SMBG. Circa 50% respondents reported having had flu vaccination. One third reported not having had an eye examination and 70% did not have a feet examination.
III. We performed an indirect estimate of type 2 diabetes based on OHAs consumption correcting for the proportion of polytherapy and non-adherence, obtaining a value similar to the one reported in the literature, which suggests that this approach could be used to monitor diabetes prevalence. We also performed a systematic review of the literature to collect risk scores to identify patients with undiagnosed type 2 diabetes. The search strategy retrieved 136 abstracts which led to the inclusion of ten articles.
Keywords: Type 2 diabetes mellitus, drug consumption data, DHD, drug utilization studies, prevalence estimation, systematic review, diabetic care.
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Prevalence and Determinants of Depression in Patients with Type 2 Diabetes visiting Tertiary Care Centre in North India
by AMIT RAVAL
Background & objectives: Depression is common among people with diabetes and it is associated with poor outcomes.... more
Background & objectives: Depression is common among people with diabetes and it is associated with poor outcomes. This study was carried out to investigate the prevalence and determinants of depression in patients with established type 2 diabetes (T2DM) attending a tertiary care hospital in north India.
Methods: Patients with established T2DM were evaluated for depression by administering the nine-item PHQ-9 (Hindi version). Binary logistic regression model was used to examine association between predictor variables and risk of depression. Results were expressed as odds ratio and 95 per cent confidence interval. Cronbach alpha was calculated to assess internal consistency of PHQ-9.
Results: Patients with T2DM (n=300) were evaluated [147(49%) male and 153(51%) female]. The median duration of diabetes (IQ) was 8(4-13) yrs. Of the study patients, 68 (23%) met the criteria for major depression, 54 (18%) for moderate depression and the remaining 178 (59%) had no clinically significant depression. Depression was strongly associated with age >54 yr (OR 1.26, 95% CI 1.02-1.67; P<0.05), central obesity (OR 1.34, 95% CI 1.04-1.64; P<0.001), neuropathy (OR 1.94, 95% CI 1.03-3.66; P=0.002), nephropathy (OR 1.81, 95% CI 1.02-3.21; P=0.041), peripheral vascular disease (OR 6.08, 95% CI 1.07-34.6; P=0.042), diabetic foot disease (OR 2.32, 95% CI 1.06-5.86; P<0.001) and pill burden (>4) (OR 1.27, 95%CI 1.01-1.44; P=0.035 ). However, the likelihood of depression was not significant with duration of diabetes and insulin use.
Interpretation & conclusion: This study showed high prevalence of depression in patients with T2DM. The risk factors for depression were age, central obesity, diabetic complications particularly neuropathy and diabetic foot disease and increased pill burden.
Patterns of prescription of antimicrobial agents in the Department of Otorhinolaryngology in a tertiary care teaching hospital
The objective of this research is to study the pattern of antimicrobial prescription in outpatient (OPD)
and... more
The objective of this research is to study the pattern of antimicrobial prescription in outpatient (OPD)
and inpatient (IPD) of the Department of Otolaryngology in a tertiary care teaching hospital of North India. This was a prospective study conducted at the Teerthanker Mahaveer Medical College and Research Centre, over a period of 12 months. All the patients who attended the Ear Nose and Throat (ENT) OPD and IPD were included. The results show that out of 4800 patients, only 54% (n=2600) of patients were included in the study on the basis of inclusion and exclusion criteria and 31.25 % (n=1500) were defaulters. Majority of the patients were male 60% (n = 1560). Majority of the patients had suffered from ear disorders, 55% (n=1430). The most frequently prescribed antibacterials were β- Lactams (75.68%) followed by aminoglycosides (9.43%). Among the penicillin group, the commonest drug prescribed was a combination of amoxicillin and clavulanic acid (9.58%), in cephalosporins was cefixime (37.98%) and in aminoglycosides was gentamicin (6.25%). In the concomitant medications antihistaminic were prescribed in 11.53%, proton pump inhibitors in 20.38% cases and NSAIDS in 7.26% cases. The average number of drugs used in each prescription was 2.70. All the drugs were prescribed with trade names. The average cost per prescription per day in OPD and IPD patients were Rs.45 and Rs.185, respectively. Out of 2600 patients; culture sensitivity tests were performed for only 71 patients (inclusive of OPD and IPD). Of which only 43 patients depicted a positive culture sensitivity tests. Our study showed that antimicrobials were mostly prescribed in patients of ear diseases while it was least in throat disorders. Proton pump inhibitors were the most common concomitant drug used. The cost of treatment in IPD patients were 4.11 times more than the OPD patients.
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Choosing the unit of measurement counts: The use of oral morphine equivalents in studies of opioid consumption is a useful addition to defined daily doses
Published in Palliative Medicine, 2011.
Co-authored with Olav Fredheim, Andreas Mellbye, Petter Borchgrevink, Katri Hamunen and Ola Dale
Aim: Defined daily dose (DDD) is the most common measurement unit used in drug consumption studies. The DDD for... more
Aim: Defined daily dose (DDD) is the most common measurement unit used in drug consumption studies. The DDD for opioids may not reflect their relative clinical potencies. The aim of this study was to explore whether opioid consumption data may be interpreted differently when adding oral morphine equivalent (OMEQ) dose as a measurement unit compared with using DDD.
Methods: The equianalgesic ratio of each opioid relative to morphine was tabulated. Data on opioid consumption expressed in DDD were converted to OMEQs using the equianalgesic ratios. The opioid consumption was compared in three different study settings: clinical data from an opioid switching study, trends within one country and a comparison between countries.
Results: Using DDD, the opioid consumption in Norway between 2004–2008 increased of 6.7%, while the increase was 23.6% using OMEQ. While DDD/1000 inhabitants/day showed that Sweden had the highest consumption of opioids among the Nordic countries, OMEQ/1000 inhabitants/day showed that Denmark had the highest consumption. In the switching study DDD indicated a reduction in analgesic dosing and OMEQ an increase when switching from WHO step II to III.
Conclusion: OMEQ reflects clinical dosing better than DDD, and can give additional insight into opioid consumption when combined with DDD. Using OMEQ can also lead to different conclusions in opioid consumption studies compared with using DDD alone.
Angiotensin II receptor blockers and risk of cancer in patients with systemic hypertension.
by Yu Chun Chen
Background Statins have pleiotropic effects, with potential clinical applications beyond their lipid-lowering
effect. We hypothesized that statins could inhibit airway inflammation. The aim of our study was to determine
whether statin use may reduce hospitalization in patients with asthma.
Materials and methods We conducted a nationwide population-based study to investigate the possible
influence of statin use on patients with asthma using the Taiwan National Health Insurance Database.
Results A total of 3965 patients with asthma (mean age 60Æ69 ± 0Æ39 years, male 41Æ3%) who received statins
after asthma diagnosis were identified from the 1 000 000 sampling cohort data set between January 2000 and
December 2007. Another 7843 patients with asthma who were matched for age, gender and medication for
asthma treatment but did not use statin were enrolled as the control group. The patients with statin use had
more hypertension (P < 0Æ001), diabetes mellitus (P < 0Æ001), coronary artery disease (P < 0Æ001), dysrhythmia
(P = 0Æ001) and chronic kidney disease (P < 0Æ001) than patients without statin use. Till the end of 2007, there
were 974 patients who were hospitalized because of asthma. After multivariate analysis, only increasing age
(hazard ratio, 1Æ02; 95% confidence interval, 1Æ02–1Æ03, P < 0Æ001) and statin use (hazard ratio, 0Æ82; 95% confidence
interval, 0Æ71–0Æ95, P = 0Æ006) were independently associated with the decreased risk of hospitalization
for asthma.
Conclusions Statin use is associated with reduced hospitalization for asthma attack in patients with asthma,
suggesting possible applications of statin in patients with asthma.
Keywords Asthma, hospitalization, national health insurance, statin.
Eur J Clin Invest 2010
Statin use reduces hospitalization in patients with asthma- A nationwide population-based study.
by Yu Chun Chen
Eur J Clin Invest. 2010 Dec 3. doi: 10.1111/j.1365-2362.2010.02434.x. [Epub ahead of print]
Huang CC, Chan WL, Chen YC, Chen TJ, Chou KT, Lin SJ, Chen JW, Leu HB.
Eur J Clin Invest 2010 ABSTRACT: Background Statins have pleiotropic effects,
with potential clinical... more
Eur J Clin Invest 2010 ABSTRACT: Background Statins have pleiotropic effects,
with potential clinical applications beyond their lipid-lowering effect. We
hypothesized that statins could inhibit airway inflammation. The aim of our study
was to determine whether statin use may reduce hospitalization in patients with
asthma. Materials and methods We conducted a nationwide population-based study
to investigate the possible influence of statin use on patients with asthma using
the Taiwan National Health Insurance Database. Results A total of 3965 patients
with asthma (mean age 60·69 ± 0·39 years, male 41·3%) who received statins after
asthma diagnosis were identified from the 1 000 000 sampling cohort data set
between January 2000 and December 2007. Another 7843 patients with asthma who
were matched for age, gender and medication for asthma treatment but did not use
statin were enrolled as the control group. The patients with statin use had more
hypertension (P < 0·001), diabetes mellitus (P < 0·001), coronary artery disease
(P < 0·001), dysrhythmia (P = 0·001) and chronic kidney disease (P < 0·001) than
patients without statin use. Till the end of 2007, there were 974 patients who
were hospitalized because of asthma. After multivariate analysis, only increasing
age (hazard ratio, 1·02; 95% confidence interval, 1·02-1·03, P < 0·001) and
statin use (hazard ratio, 0·82; 95% confidence interval, 0·71-0·95, P = 0·006)
were independently associated with the decreased risk of hospitalization for
asthma. Conclusions Statin use is associated with reduced hospitalization for
asthma attack in patients with asthma, suggesting possible applications of statin
in patients with asthma.
The effect of weather on peritoneal dialysis prescription - seasonal variation in PD dialysate utilization.
by Yu Chun Chen
Perit Dial Int. 2010 May-Jun;30(3):320-8. Epub 2010 Mar 25.
Chen TW, Li SY, Chen TJ, Chen YC, Lai CL, Chen JY, Chou LF.
BACKGROUND: There have been no reports on peritoneal dialysis (PD) solution
utilization since this treatment was... more
BACKGROUND: There have been no reports on peritoneal dialysis (PD) solution
utilization since this treatment was developed in the 1920s. The aim of the
present investigation was to investigate if weather affects PD prescription.
Study Design and
METHODS: This 10-year observational study used the Taiwan National Health
Insurance Research Database. Setting and Participants: Claims for different
concentrate PD dialysate were analyzed monthly. 2.5% and 4.25% PD solutes were
defined as hypertonic solutions. Predictor: Monthly outdoor mean temperature.
Outcome and Measurement: The relationship between monthly mean of PD dialysate
utilization and monthly outdoor temperature was analyzed by linear regression.
Monthly mean PD dialysate utilization amount in 4 quarters was analyzed by ANOVA.
RESULTS: During the 10-year study period, a clear seasonal variation in PD
dialysate was observed. This seasonal variation was present regardless of age,
gender, and the presence of hypertension, diabetes, and dyslipidemia. Monthly
mean temperature was positively correlated to 1.5% dialysate utilization amount
(r = 0.559, p < 0.001) and negatively correlated to 2.5% (r = -0.533, p < 0.001)
and 4.25% (r = -0.410, p < 0.001) dialysate utilization amount. In longitudinal
follow-up, hypertonic PD fluid utilization was higher in diabetic patients than
in nondiabetic patients from the beginning of treatment. Thereafter, it increased
rapidly and reached a plateau within 1 year. Limitations: Analysis of
ultrafiltration amount, blood pressure, and body weight was unfeasible due to the
nature of the database.
CONCLUSION: The utilization of differential strengths of PD solutions has a
seasonal cyclic pattern, with more hypertonic PD solution utilized in winter and
more hypotonic PD solution in summer.
Potentially inappropriate medication for emergency department visits by elderly patients in Taiwan.
by Yu Chun Chen
Pharmacoepidemiol Drug Saf. 2009 Jan;18(1):53-61.
Chen YC, Hwang SJ, Lai HY, Chen TJ, Lin MH, Chen LK, Lee CH.
PURPOSE: The potential for adverse drug events caused by potentially
inappropriate medication (PIM) use in... more
PURPOSE: The potential for adverse drug events caused by potentially
inappropriate medication (PIM) use in elderly patients at emergency department
(ED) visits is a growing concern. The objects of this study were to determine the
prevalence, characteristics and risk factors of PIM use among elderly ED visits
in Taiwan.
METHODS: The nationwide computerized claims database of elderly ED visits under
the National Health Insurance (NHI) in Taiwan during 2001-2004 was accessed. PIM,
independent of diseases diagnoses or conditions and should be generally be
avoided in elderly people, was evaluated using the updated 2003 Beers criteria.
RESULTS: Between 2001 and 2004, 14.7% of total 1 429 463 elderly ED visits with
prescriptions had PIM, and 19.3% of elderly people who visited ED received at
least one PIM annually. Odds ratio for PIM prescriptions to ED elderly was higher
for visits at which more drugs were prescribed, visits at local community
hospital, female and older physicians, patients aged 65-69 years and female
patients. Common PIM categories were short acting nifedipine, muscle relaxants
and anti-spasmodics, antihistamines and ketorolac. When health care resource
utilization was compared in 2004, subjects receiving PIM at ED visit had
significantly more mean ambulatory care visits, ED visits and hospital admissions
than subjects who did not receive PIM.
CONCLUSIONS: About one fifth of elderly people who visited ED received PIM
annually in Taiwan. The public and physicians should be educated, and a
computerized drug surveillance system might be needed to avoid PIM prescriptions
to the ED elderly patients.
Lower Copay and Oral Administration: Predictors of First-Fill Adherence to New Asthma Prescriptions
Zackary Berger, MD, PhD; William Kimbrough, MD; Colleen Gillespie, PhD; Joseph A. Boscarino, PhD, MPH;G. Craig Wood, MS; Zhengmin Qian, MD, PhD; J. B. Jones, PhD, MBA; Nirav R. Shah, MD, MPH
Background: Nonadherence to asthma medications is associated with increased emergencydepartment visits and... more Background: Nonadherence to asthma medications is associated with increased emergencydepartment visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is knownabout first-fill adherence with asthma medications and the factors for no-fill.Objective: The goal of the study was to examine the proportion of patients who fill a new pre-scription for an asthma medication and analyze characteristics associated with this first-fill.Methods: This retrospective cohort study linked electronic health records with pharmacy claims.The cohort was comprised of 2023 patients aged 18 years or older who sought care from theGeisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthmamedication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescriptionfilled by the patient within 30 days of the prescription order date. Covariates examined included factors related to thepatient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office vis-its, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with acopay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients pre-scribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed throughsimple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary med-ications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreas-ing copay may improve adherence and, therefore, asthma control. [AHDB. 2009;2(4):174-180