MSc (Med), Faculty of Health Sciences, University of the Witwatersrand, 2010

Opioid prescribing within the workers’ compensation system in general has been a cause for concern. The objective of the study was to estimate the prevalence of opioid users among injured workers, referred at a Tertiary Care Pain Clinic, in 2008-2009. A cross-sectional retrospective study of 110 consecutive workers; male/female ratio was 2.3:1; mean age 45.5 years; mean pain ratings were 7.1±1.8. 21% of the workers were diagnosed with a biomedical problem (Group I), 51% with medical/psychological factors (Group II) and 25.5% had identifiable psychological factors but no physical pathology (Group III). Opioids were prescribed in 81.8%; of those 32.2% were on >200mg of daily morphine or equivalent (MED). A higher proportion of opioid users were in Group II and Group III than Group I. The vast majority of referred injured workers in this study were on opioid therapy with 1 in 3 exceeding the “watchful” dose of 200 mg MED

Opioid prescribing within the workers’ compensation system in general has been a cause for concern. The objective of the study was to estimate the prevalence of opioid users among injured workers, referred at a Tertiary Care Pain Clinic, in 2008-2009. A cross-sectional retrospective study of 110 consecutive workers; male/female ratio was 2.3:1; mean age 45.5 years; mean pain ratings were 7.1±1.8. 21% of the workers were diagnosed with a biomedical problem (Group I), 51% with medical/psychological factors (Group II) and 25.5% had identifiable psychological factors but no physical pathology (Group III). Opioids were prescribed in 81.8%; of those 32.2% were on >200mg of daily morphine or equivalent (MED). A higher proportion of opioid users were in Group II and Group III than Group I. The vast majority of referred injured workers in this study were on opioid therapy with 1 in 3 exceeding the “watchful” dose of 200 mg MED

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24881号 / 医博第5015号 / 新制||医||1068(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 古川 壽亮, 教授 髙橋 良輔, 教授 阪上 優 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Au vu de la croissance considérable de la consommation des antidépresseurs au cours des dernières décennies et de la part non négligeable de patients qui restent non traités ou mal traités, la question du bon usage ou du mésusage de ces médicaments s’impose. Les trois études présentées dans ce rapport se sont intéressées à décrire l’augmentation de la consommation des antidépresseurs et à en comprendre les mécanismes sous-jacents. L’analyse des données de vente indique que la croissance des antidépresseurs diffère entre les pays étudiés, mais qu’elle suit un schéma classique d’augmentation suivie d’une stabilisation à un certain seuil, et que les politiques de limitation des dépenses de santé ont un impact, différent selon la maturité du marché. Les travaux sur données de remboursement montrent que si l‘on peut parler de mésusage dans l’utilisation des antidépresseurs, il semble lié non pas à une prescription hors indication mais plutôt inappropriée : traitement sans diagnostic précis, prescription unique suggérant un traitement injustifié, traitement trop court en regard des recommandations internationales qui préconisent au moins 6 mois pour éviter rechutes et récidives. Les travaux que nous avons menés montrent que les bases de données peuvent constituer un outil fiable d’évaluation de la consommation (données de vente) ou d’utilisation des antidépresseurs (bases de remboursement) : utilisation simple et rapide de données de vente afin d’avoir un panorama des pratiques et utilisation plus complexe des bases de remboursement afin de mieux comprendre les pratiques. Utilisés en pratique courante, des tableaux de bord de suivi de consommation pourraient alerter les pouvoirs publics sur les dérives des consommations et permettre de mettre en place des analyses plus poussées afin de caractériser les pratiques et mieux comprendre les vecteurs de la consommation. / Considering the large increase in antidepressant use observed in the last decades, the question of good or poor usage of antidepressants is of importance. The three studies presented in this report consisted into a descriptive analysis of the increase in the use of antidepressants in different countries, and thereafter analyse the underlying mechanisms. Our analysis of sales database indicates that the increase in antidepressants volume differ from country to country, but follows a classical scheme with rapid increase until stabilisation to a certain threshold and that national policies to ensure expenditure limitations has a different impact on the volume depending on the maturity of the market. The analyses performed afterwards on US claims databases, and show that if improper use of antidepressants is a reality, it does not seem to correspond to a massive off-label use but rather to an incorrect use of antidepressants: treatment without precise diagnosis, isolated prescription which suggest undue treatment, treatment for too short periods of time with regards to international guidelines which recommend at least 6 month to avoid relapse or recurrence of the disease. The analyses we have conducted on databases can serve as a basis for the development of a reliable tool to evaluate drug consumption (sales databases) or drug use (claims databases) : simple and rapid use of sales databases to get a mapping of consumption in their environment, and more complex and time consuming use of claims database to gain an understanding of practice. Used in routine, the sales monitoring tools could play a role to alert public health services on abnormal evolution of drug consumption and allow the initiation of more refined analyses either on large claims databases or through prospective cohort of patients in order to characterise the practice and gain an understanding on the drivers of drug use.