Sedative-hypnotic guideline, BHS Judith Martin, Md Medical Director of Substance use services, SFDPH

Disclosures: No conflicts of interest for this talk.

Quality Management incident reports, 2010-2011 reviewed 55 deaths came to the attention of CBHS during 2010-2011, of patients enrolled in MMT. (most from incident report, collected by Melissa Bloom, QI) Focused on 14 opioid unintentional overdose deaths of patients in treatment (2 week window) Tried to obtain medical examiner report Collateral check of list from Phillip Coffin, Director of SUD Research, who is doing research on all city opioid overdose deaths.

2010/2011 accidental opioid overdose deaths reported by methadone clinics   DOD LDS/(cls) Open Age Sex Pgm 1 5-17-10 5-10-10 2005 65 m 2 4-13-11 4-12-11 59 3 2-23-11 2-20-11 1999 70 4 8-3-10 8-1-10 2002 5 5-28-11 5-29-11 f 6 10-25-10 10-24-10 40 7 2-9-11 2-7-11 2008 50 8 2-6-11 2-3-11 2006 60 9 12-6-10 11-29-10 2009 33 10 11-18-10 11-14-10 7mo 46 11 8-5-10 8-4-10 56 12 6-11-10 2007 45 13 1-8-11 2004 61 14 9-30-11 9-25-11 2010

Cause of death and tox screen COD/other me op Bz sed coc al   Coc/CVA x Mixed X Mo Prom p Pol/Copd (OD) (p) ? Traz mOD Quet Hc x/m Poly Sert,phenob Sert,quet P “poly” mOD/COPd mOD, Copd

Possible areas to address: 8/14 had sedatives present. 8/14 had cocaine present. Several noted lung disease as a co-morbidity. ( opioid overdose is related to breathing) Most deaths occurred in patients long into treatment, ie “they’ve been on it for years” isn’t protective, misconceived as safe.

Patients receiving buprenorphine at CBHS: Sedative/Hypnotic Prescriptions by CURES report: Michelle Geier, Pharm D

Study Findings: Buprenorphine and Sedative/Hypnotic Prescriptions Results Number of clients with a sedative or hypnotic 36 (19%) Average benzodiazepine dose (clonazepam equivalence) 2.5mg/day Benzodiazepine dose range 0.25mg – 15mg/day

Active Infoscriber Orders Dec 2013 Benzodiazepines and Zolpidem Comparison Drug Number of Active Orders Risperidone 1914 Trazodone 1623 Bupropion 1308 Sertraline 1277 Aripiprazole 1002 Citalopram 962 Drug Number of Active Orders Average Daily Dose (mg) Clonazepam 1549 1.72 Lorazepam 893 1.74 Zolpidem 574 9.10 Temazepam 138 24.18 Diazepam 68 13.78 Alprazolam 67 1.84

Next steps taken: Presented information to CBHS executive team and to Medication Use Improvement Committee (MUIC) which formed a subgroup that developed a benzodiazepine guideline. CBHS prescriber quarterly meeting on January 9th dedicated to presenting data, guideline, and getting BHS prescriber responses CURES registration drive Implementation varies Use active prescriptions as measure

Highlights of CBHS benzodiazepine guideline: (see handout) Components: - using non-sedative options - risk analysis - peer consultation check CURES when prescribing or considering benzodiazepines Evaluate for opioid use: pain, methadone, buprenorphine, etc. Evaluate for history of or active substance use disorder, including alcohol. Evaluate fragility, fall risk, age Discontinue, taper, consult if above checks positive.