Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

BackgroundCanadians have long been proud of their universal health insurance system, which publicly funds the cost of physician visits and hospitalizations at the point of care. Prescription drugs however, have been subject to a patchwork of public and private coverage which is frequently inefficient and creates access barriers to necessary medicine for many Canadians.MethodsA narrative review was undertaken to understand the important economic, policy and political considerations regarding implementation of universal prescription drug access in Canada (pan-Canadian pharmacare). PubMed, SCOPUS and google scholar were searched for relevant citations. Citation trails were followed for additional information sources. Published books, public reports, press releases, policy papers, government webpages and other forms of gray literature were collected from iterative internet searches to provide a complete view of the current state on this topic.Main findingsRegarding health economics, all five of the reviewed pharmacare simulation models have shown reductions in annual prescription drug expenditure. However, differing policy and cost assumptions have resulted in a wide range of cost-saving estimates between models. In terms of policy, a single-payer, ‘first-dollar’ coverage model, using a minimum national formulary, is the model most frequently advocated by the academic community, healthcare professions and many public and patient groups. In contrast, a multi-payer, catastrophic ‘last-dollar’ coverage model, more similar to the current “patchwork” state of public and private coverage, is preferred by industry drug manufacturers and private health insurance companies. Primary concerns from the detractors of universal, single-payer, ‘first-dollar’ coverage are the financing required for its implementation and the access barriers that may be created for certain patient populations that are not majorly present in the current public-private payer mix.ConclusionCanada patiently awaits to see how the issue of prescription drug coverage will be resolved through the work of the Advisory Council on the Implementation of National Pharmacare. The overarching and ongoing discourse on policy and program implementation may be construed as a political debate informed by divergent public and private interests.Electronic supplementary materialThe online version of this article (10.1186/s40545-018-0154-x) contains supplementary material, which is available to authorized users.

Drug utilization research on benzodiazepines remains important for measuring trends in consumption within and across borders over time for the sake of monitoring prescribing patterns and identifying potential population safety concerns. The defined daily dose (DDD) system by the World Health Organization (WHO) remains the internationally accepted standard for measuring drug consumption; however, beyond consumption, DDD-based results are difficult to interpret when individual agents are compared with one another or are pooled into a total class-based estimate. The diazepam milligram equivalent (DME) system provides approximate conversions between benzodiazepines and Z-drugs (i.e. zopiclone, zolpidem, zaleplon) based on their pharmacologic potency. Despite this, conversion of total dispensed benzodiazepine quantities into DME values retains diazepam milligrams as the total unit of measurement, which is also impractical for population-level interpretation. In this paper, we propose the use of an integrated DME-DDD metric to obviate the limitations encountered when the component metrics are used in isolation. Through a case example, we demonstrate significant change in results between the DDD and DME-DDD method. Unlike the DDD method, the integrated DME-DDD metric offers estimation of population pharmacologic exposure, and enables superior interpretation of drug utilization results, especially for drug class summary reporting.

Purpose:  1) To evaluate trends for benzodiazepines (BZD) and Z-Drugs over 15-years in a general Canadian adult population measured by: a) consumption b) pharmacologic exposure c) dose intensity and d) prevalence of use. 2) To demonstrate the utility of Diazepam Milligram Equivalence (DME) based measurements when used in conjunction with traditional standard measurements of drug utilization such as the Defined Daily Dose (DDD) system. Methods: Administrative data covering all prescriptions from April 2001-March 2016 for BZD and Z-Drugs for patients ≥18 years was used. Consumption was calculated as DDD/1000-person days. Dose intensity (DI) was determined by conversion of individual daily doses to Diazepam Milligram Equivalents (DME). Pharmacologic exposure (PE) was calculated as DME-DDD/1000-person days. Prevalence was determined as the proportion of the adult population with receipt of ≥1 prescription in a given year. Changes were assessed using either Poisson or simple linear regression at an alpha of 0.05. Results:  Z-Drug usage (~99% zopiclone) statistically increased on every measure over the course of the study period; consumption (8.2 to 28.6 DDD/1000-person days), PE (4.1 to 14.3 DME-DDD/1000-person days), DI (5.0 to 5.43 DME/day) and prevalence (2.0% to 4.8%). For BZD the only statistically significant changes were in DI (17.1 to 20.1 DME/day) and prevalence (9.3% to 8.1%). Consumption and PE gradually increased from 2001 to 2011 for BZD before declining thus producing a non-significant trend for BZD. Conclusion: 1) Z-Drug usage increased markedly from 2001 to 2016 whereas BZD use only increased in terms of DI. 2) DME-based measurements enable further interpretation of BZD utilization compared to sole reliance on DDD.

Background: Medication reviews are a structured clinical intervention with the general goals of improving patient drug knowledge and detecting and resolving drug-related problems in an individual patient's medication regimen. A variety of barriers entrenched in the traditional drug distribution and dispensing model of pharmacy business has continued to challenge the implementation efforts of medication review services worldwide in the community pharmacy setting.Main Objectives: i) Characterize original research studies that sought to enhance medication review service implementation in community pharmacy settings. ii) Categorize the broader corpus of scientific literature (beyond original implementation studies) on medication review service implementation in community pharmacy settings.Methods: a broad systematic search strategy was applied to ovid MEDLINE, Embase, CINAHL and Cochrane Library to create an over-arching view and extensively ordered bibliography of the diverse research publication types dealing with the topic of medication review service implementation in the community pharmacy setting. A scoping review was subsequently conducted on original research studies that utilized various strategies to enhance the implementation of this service in community pharmacies. Data-charting evaluated the location of implementation studies, the strategies undertaken, the scale of implementation strategies, the use of DII (Dissemination, Implementation and Improvement) science theory, sample sizes, and DII outcomes.Results: Of 5,947 records screened, 419 fulfilled the inclusion criteria (from abstract screening) to be deemed suitable for categorization and inclusion into the broader survey on this topic. Of these 419 publications, only 75 were original research specifically focused on enhancing the implementation of medication reviews in community pharmacy. A large majority of the publications were qualitative studies (n = 203). The remaining articles were improvement studies (n = 36), descriptive observational studies (n = 49), reviews (n = 69) and methodology papers (n = 16). Twenty-nine of these articles were deemed suitable for inclusion in more than one category. After full-text screening, 41 of the 75 implementation publications, representing 40 original studies, published between 1999-2019, were eligible for data-charting. The majority of these studies occurred in North America (n = 30), used some form of education as the most common implementation strategy (n = 22) and measured 'adoption' (extent or frequency of medication reviews delivered) most frequently as an implementation outcome (n = 30). Just over half of the studies used a multi-faceted implementation strategy (n = 21). Only 9 studies used a theory, model or framework at any point in the research process to test hypotheses or explain empirical findings. Conclusions:There is an abundance of publications addressing various issues surrounding medication review implementation in community pharmacies. However, the literature appears disproportionately repre...