Volume 199 - Issue 11
Systematic postmarketing surveillance needed for misused psychoactive pharmaceutical drugs
Author: Steven Moylan
Med J Aust 2013; 199 (11): 746-747. || doi: 10.5694/mja13.10482
Published online: 16 December 2013
Published online: 16 December 2013
To the Editor: Rintoul and colleagues showed that alprazolam is being increasingly detected in heroin-related deaths.1 One explanation provided is increased rates of alprazolam misuse among people who inject drugs.
My colleagues and I recently reviewed the role of alprazolam in Australian clinical practice,2 focusing on the sole supported Pharmaceutical Benefits Scheme (PBS) indication: treatment of “panic disorder where other treatments have failed or are inappropriate”. ...
To the Editor: Rintoul and colleagues showed that alprazolam is being increasingly detected in heroin-related deaths.1 One explanation provided is increased rates of alprazolam misuse among people who inject drugs.
My colleagues and I recently reviewed the role of alprazolam in Australian clinical practice,2 focusing on the sole supported Pharmaceutical Benefits Scheme (PBS) indication: treatment of “panic disorder where other treatments have failed or are inappropriate”. Despite this narrow indication, PBS prescriptions increased 93% between 1997 and 2007, and total drug intake increased from 3.88 mg to 5.12 mg per 1000 population per day between 2003 and 2007, while use of other benzodiazepines remained stable or fell. The increase occurred despite updated treatment guidelines recommending psychological treatment (eg, cognitive behaviour therapy) and alternative pharmacological treatments (eg, selective serotonin reuptake inhibitors) before benzodiazepines, with specific warnings against benzodiazepine use beyond the short term (4 weeks) due to risks of addiction and side effects.3 These recommendations should have reduced alprazolam prescription, but this was not the case.
While there are many possible explanations for increasing prescription rates,2 it is most concerning that these trends have correlated with increasing alprazolam-related harm. Additionally, alprazolam appears easy to access4 and is traded on the black market. At least four state and territory health departments and medical boards have identified increasing use of alprazolam as problematic and sought to engage practitioners in education,5 resulting in some reduction in prescription rates.6 However, escalating rates of harm suggest a more interventionist approach is required. The recent move to elevate alprazolam to Schedule 8 is one important step and, coupled with continuing prescriber education, will hopefully lead to a reduction in alprazolam-related harm.
Competing interests
No relevant disclosures.
References
- Rintoul AC, Dobbin MDH, Nielsen S, et al. Recent increase in detection of alprazolam in Victorian heroin-related deaths. Med J Aust 2013; 198: 206-209. CHDFCCAC
- Moylan S, Giorlando F, Nordfjaern T, Berk M. The role of alprazolam for the treatment of panic disorder in Australia. Aust N Z J Psychiatry 2012; 46: 212-224. CBBEDFHF
- National Institute for Health and Clinical Excellence. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. NICE clinical guideline 113. London: NICE, 2011. i1142875
- Best D, Wilson A, Reed M, et al. Alprazolam and wider benzodiazepine misuse in Australia — sources of supply and evidence of harms. Aust N Z J Psychiatry 2013; 47: 94-95. i1142878
- Medical Practitioners Board of Victoria. Warning: alprazolam (Xanax, Kalma, Zamhexsal). Bulletin 2009; (Jun): 11.
- Galloway J. Newsletter number 42. Information circular for pharmacists in Tasmania. New restrictions on the prescribing of alprazolam. Hobart: Department of Health and Human Services, 2007. i1142882