David Braunstein

OPPIDUM surveillance program: 20 years of information on drug abuse in France.

It is important to assess drug abuse liability in ‘real life’ using different surveillance systems. Some are based on specific population surveys, such as individuals with drug abuse or dependence, or under opiate maintenance treatment, because this population is very familiar with drugs and is more likely to divert or abuse them. In France, an original surveillance system based on this specific population and called ‘Observation of illegal drugs and misuse of psychotropic medications (OPPIDUM) survey’ was set up in 1990 as the first of its kind. The aim of this article is to describe this precursor of French drug abuse surveillance using different examples, to demonstrate its ability to effectively give health authorities and physicians interesting data on drug abuse. OPPIDUM is an annual, cross‐sectional survey that anonymously collects information on abuse and dependence observed in patients recruited in specialized care centers dedicated to drug dependence. From 1990 to 2010, a total of 50 734 patients were included with descriptions of 102 631 psychoactive substance consumptions. These data have outlined emergent behaviors such as the misuse of buprenorphine by intravenous or nasal administration. It has contributed to assess abuse liability of emergent drugs such as clonazepam or methylphenidate. This surveillance system was also able to detect the decrease of flunitrazepam abuse following implementation of regulatory measures. OPPIDUMs twenty years of experience clearly demonstrate that collection of valid and useful data on drug abuse is possible and can provide helpful information for physicians and health authorities.

Detection of signals of abuse and dependence applying disproportionality analysis

IntroductionPrescription drug abuse and dependence is a widespread phenomenon in many countries. The use of disproportionality measures in drug abuse surveillance is rarely performed.PurposeThe aim of this study is to determine the occurrence of signals of abuse and dependence for different psychoactive drugs in real-life settings.MethodsDisproportionality analysis was realised from a database specifically constructed for the monitoring of drug abuse and dependence. This database provides information on approximately 5000 patients and 8000 consumption modalities for more than 100 distinct psychoactive medications for 2010 and 2011. Proportional reporting ratio (PRR) was computed in two population groups: subjects under an opiate maintenance treatment (OMT) versus those not under OMT, and focused on four types of behaviours: abuse and dependence, illegal acquisition, diverted route of administration and concomitant alcohol use.ResultsAmong the 100 psychoactive drugs for which a signal could be detected, those presenting the highest signals were the following: flunitrazepam, clonazepam, methylphenidate, ketamine, morphine sulfate, codeine and buprenorphine.ConclusionsThe present study shows an innovative application of disproportionality measures for drug abuse monitoring based on two cross-national, annual studies. The disproportionality analysis provided the opportunity to reveal and compare the magnitude of signals between 100 psychoactive drugs. This approach helps to compare the magnitude of abuse and dependence behaviours for a large number of drugs, and allows prioritizing actions in a context where such events are usually underreported.

Triptans use and overuse: A pharmacoepidemiology study from the French health insurance system database covering 4.1 million people

Introduction The objective of this study was to estimate and to characterize the actual patterns of triptan use and overuse in France using a drug reimbursement database. Methods We included all people covered by the French General Health Insurance System (GHIS) from the Provence-Alpes-Côte-d’Azur (PACA) and Corsica administrative areas who had at least one dispensed dose of triptans between May 2010 and December 2011. All dispensed doses of triptans, migraine prophylactic treatment and psychotropic medications were extracted from the GHIS database. Triptan overuse was defined as triptan use >20 defined daily doses (DDD) per month on a regular basis for more than three consecutive months. Risk of overuse was assessed using logistic regression adjusted for gender and age. Results We included 99,540 patients who had at least one prescription of a triptan over the 20 months of the study. Among them, 2243 patients (2.3%) were identified as overusers and received 20.2% of the total DDD prescribed. Twelve percent of overusers and 6.9% of non-overusers were aged more than 65 years (OR: 1.81). Overusers did not have a greater number of prescribers and pharmacists than non-overusers. They were more frequently prescribed a prophylactic medication for migraine treatment (56.8% vs 35.9%, OR: 2.36), benzodiazepines (69.9% vs 54.7%, OR: 1.93) and antidepressants (49.4% vs 30.2%, OR: 2.33). Conclusions This work suggests that triptan overuse may be due to insufficient prescriber awareness of appropriate prescribing. The off-label prescription of triptans among the elderly necessitates investigating their cardiovascular risk profile in this sub-group.

Antidepressant adherence patterns in older patients: use of a clustering method on a prescription database.

According to the World Health Organization, depression will become the second most important cause of disability worldwide by 2020. Our objective was to identify patterns of adherence to antidepressant treatments in older patients using several indicators of adherence and to characterize these patterns in terms of medication exposure. We conducted a retrospective cohort study using the French National Health Insurance reimbursement database. Incident antidepressant users aged more than 65 were included from July 1, 2010, to June 30, 2011, and followed up for 18 months. Antidepressant and other psychotropic drugs (opioids, benzodiazepines, antipsychotics, anti‐epileptics) were recorded. Adherence to antidepressant treatment was assessed by several measures including proportion of days covered, discontinuation periods, persistence of treatment, and doses dispensed. Patients were classified according to their adherence patterns using a mixed clustering method. We identified five groups according to antidepressant adherence. One group (n = 7505, 26.9%) was fully adherent with regard to guidelines on antidepressant use. Two patterns of nonadherent users were identified: irregular but persistent users (n = 5131, 18.4%) and regular but nonpersistent users (n = 9037, 32.4%). Serotonin reuptake inhibitors were the most frequently dispensed antidepressant class (70.6%), followed by other antidepressants (43.3%, mainly serotonin–norepinephrine reuptake inhibitors and tianeptine) and tricyclic antidepressants (TCAs) (13.4%). Nonadherent users more frequently had a dispensing of TCA, opioid, and anti‐epileptic medication than adherent users. Health policies to improve adherence to antidepressant treatment may require better training of physicians and pharmacists, insisting on the important role of the continuation period of antidepressant treatment.

Ergot Use and Overuse: A Pharmacoepidemiology Retrospective Cohort Study

The objective of this study was to estimate and to characterize the actual patterns of ergot use and overuse in France using a drug reimbursement database.

Comment mesure-t-on le bénéfice net d’un traitement ?

Resume L’estimation du benefice net permet d’expliciter les fondements des decisions therapeutiques, individuelles et collectives. Cette explicitation est une exigence dans la decision medicale partagee et la pratique de la medecine factuelle ou evidence-based medicine. De nombreuses methodes existent, sans qu’aucune ne puisse s’imposer face a un cahier des charges complexe et devant s’ajuster a l’attente de l’acteur central, le patient ou la societe, et a un eventail infini des contextes possibles. Les enjeux, les limites, les contraintes et les competences a acquerir par tous les acteurs, ont ete discutees par les participants de la table ronde et font l’objet de cet article, permettant de conclure a quelques messages cles et des recommandations. Les efforts de formation de tous les acteurs representent la priorite essentielle.

How to measure the net benefit of treatment

Estimating net benefit makes possible to clarify the basis for therapeutic decisions on an individual and collective level. This clarification is a must in shared medical decision-making and evidence-based medicine. Numerous methods are available, although none outweigh the others. The complex specifications of net benefit estimation should be tailored to the expectations of the central stakeholder, patient or society, and the unlimited range of potential contexts. The challenges, limitations, constraints and skills to be acquired by all stakeholders were discussed by the participants of the round table. They are described in this article, enabling key messages and guidelines to be presented. The essential priority is to ensure that all stakeholders receive the required training.

Impact d’une sensibilisation des médecins traitants sur la diminution des prescriptions d’antipsychotiques chez les résidents avec démence en Ehpad

BACKGROUND Despite the context of several national warnings, antipsychotics drugs are commonly used to treat behavioural and psychological symptoms in dementia (BPSD). AIM To observe a decrease of antipsychotic drug prescription, in old NH (nursing homes) residents with dementia, after an awareness of their general practitioner. METHODS Observational, prospective, multicenter study. The study population corresponds to NH residents with dementia, and antipsychotic drug consumption, in nursing homes volunteered to participate. Awareness-raising is carried out through information documents. The evaluation criteria is the proportion of residents under antipsychotics after sensitization. RESULTS out of the 30 nursing homes included, 26.7% of the patients were prescribed at least one antipsychotic and 15% were both demented and under antipsychotics. A total of 317 residents with dementia and antipsychotics were included 15% of the total NH population. Psychotropic drug co-prescriptions was very frequent 43.2% also used benzodiazepines, 37.2% anxiolytics and 33.1% antidepressants. Agitation, aggressiveness, opposition to care and wandering were the most commonly BPSD encountered. After a first sensitization, we obtained a 15.5% decrease of antipsychotic prescriptions. CONCLUSION A personalized sensitization towards GP allowed a reduction of antipsychotic drugs prescription in NH residents with dementia and BPSD.

What strategy should France implement for H2020

The initiation of Horizon 2020--the European Unions 8th Framework Programme for Research and Innovation, allotted a budget of 79 billion euros--provides an opportunity to review Frances participation in previous Framework Programmes. Indeed, French participation does not match either its scientific importance or its financial investment. While France contributed 16.5 to 17% of the EUs 7th Framework Programme research budget, its return through the funding of coordinated projects in which French teams are participating stands at around 12.5 to 13%, a shortfall of 600 million euros. Although the situation depends on the type of activity, French participation in clinical research appears to be smaller than that of its neighbours, with fewer responses to European calls for proposals. While France has many assets, which include the assured funding of clinical research, structured thematic networks and the initiation of major national programmes, it suffers from the dilution of resources due to Frances regional development policy, the lack of multidisciplinarity and the ignorance of both the medical and scientific community and the institutions to which they belong as to how Horizon 2020 actually works. We propose three types of strategy to encourage proposals for coordinated clinical research projects or projects involving French teams, and to help in the drawing up of applications: Broaden the vision of our children, students and colleagues, helping them to adapt to the globalisation of knowledge throughout their educational and professional lives. Recognise the value of European actions to influence the European landscape and change mentalities. Help and support project initiators by pooling skills within a limited number of expert centres designed to assist them in their funding application. • Broaden the vision of our children, students and colleagues, helping them to adapt to the globalisation of knowledge throughout their educational and professional lives. • Recognise the value of European actions to influence the European landscape and change mentalities. • Help and support project initiators by pooling skills within a limited number of expert centres designed to assist them in their funding application.

Information and Communication on Risks Related to Medications and Proper Use of Medications for Healthcare Professionals and the General Public: Precautionary Principle, Risk Management, Communication During and in the Absence of Crisis Situations

Recent drug crises have highlighted the complexity, benefits and risks of medication communication. The difficulty of this communication is due to the diversity of the sources of information and the target audience, the credibility of spokespersons, the difficulty to communicate on scientific uncertainties and the precautionary principle, which is influenced by variable perceptions and tolerances of the risk. Globally, there is a lack of training in risk management with a tendency of modern society to refuse even the slightest risk. Communication on medications is subject to regulatory or legal requirements, often uses tools and messages that are not adapted to the target audience and is often based on a poor knowledge of communication techniques. In order to improve this situation, the available information must be coordinated by reinforcing the unique medication information website and by coordinating communication between authorities by means of a single spokesperson. A particular effort must be made in the field of training in the proper use and risk of medications for both the general population and patients but also for healthcare professionals, by setting up a unified academic on-line teaching platform for continuing medical education on medications and their proper use.