Patients, prescribing, and benzodiazepines

Treating Insomnia: A Review of Patient Perceptions Toward Treatment

Patient views about their treatment for insomnia often dictate outcome. This review explores the literature relating to the patients' global perceptions toward treatment for insomnia. A strategic literature search was conducted using five databases (PubMed, CINAHL, Medline, PsycINFO, and Embase). The 57 research articles included for this review were mapped out chronologically across three key stages of treatment-seeking (pretreatment appraisal, actual treatment experiences, and posttreatment evaluation). Patient perceptions played an important role across these three key stages and influenced subsequent health behaviors such as the initiation of help-seeking, treatment uptake, treatment adherence, and treatment adjustment. Patients' perceptions toward treatment were heavily grounded by their psychosocial contexts. Clinical implications and future directions for including patient-centered metrics in mainstream practice and research are discussed.

Do Benzodiazepines Still Deserve a Major Role in The Treatment of Psychiatric Disorders? A Critical Reappraisal

Discovered in the late 1950s by Leo Sternbach, the first benzodiazepine (BZD) chlordiazepoxide was followed by several congeners, which rapidly constituted one of the largest and most widely prescribed classes of psychotropic compounds. After 50 years, BZDs are still routinely utilized not only in psychiatry but, more generally, in the whole of medicine. Despite their high therapeutic index which makes BZDs safer than other compounds like barbiturates, as well as their rapidity of onset, psychiatrists and family physicians are well aware about the controversy that surrounds the wide use – often not adequately based on scientific evidence – of BZDs in many psychiatric disorders. In this overview of international treatment guidelines, systematic reviews and randomized clinical trials, the aim was to provide a critical appraisal of the current use and role of BZDs in psychiatric disorders and their disadvantages, with specific emphasis on anxiety and affective disorders, sleep disorders, alcohol withdrawal, violent and aggressive behaviours in psychoses, and neuroleptic-induced disorders. In addition, specific emphasis has been given to the extent of usage of BZDs and its appropriateness through the assessment of available international surveys. Finally, the entire spectrum of BZD-related adverse effects including psychomotor effects, use in the elderly, paradoxical reactions, tolerance and rebound, teratologic risk, dependence, withdrawal and abuse issues was examined in detail.

Benzodiazepine and Z-drug Prescribing for Elderly People in a General Hospital: A Complete Audit Cycle

BACKGROUND

Use of benzodiazepines and Z-drugs in the elderly is associated with adverse outcomes such as increased risk of falls and fractures and cognitive impairment. We aimed to assess the prescribing practice of benzodiazepine and Z-drugs in those aged over 65 years in a general hospital against evidence based standards and to examine the effects of multidisciplinary feedback, as well as determine the prevalence of usage.

METHODS

All case-notes and medication charts of patients over the age of sixty five on surgical and medical wards in Sligo General Hospital (SGH) were retrieved and analysed over a two-day period in 2008. Data was collected in relation to benzodiazepine and Z-drug prescribing. We followed up on this initial data collection by screening discharge summaries at six weeks to assess benzodiazepine and Z-drug prescribing on discharge. Audit results were disseminated together with consensus guidelines on the prescribing of these medications in older adult population to all general practitioners in County Sligo. Educational sessions were held for both doctors and nurses in SGH. The audit cycle was completed by a re-audit of benzodiazepine and Z-drug prescribing six months from original study using identical methods.

RESULTS

We found a high prevalence of benzodiazepine and Z-drug use in original audit, 54% (38/70) of the group audited. The prevalence fell to 46% (32/70) at the re-audit post intervention. This result was not statistically significant. The percentage of patients commenced on benzodiazepine and Z-drugs prior to admission fell from 36% (25/70) at the initial audit to 23% (16/70) at the re-audit.

CONCLUSION

Prescribing practices were not in keeping with consensus guidelines as highlighted by this relatively basic audit cycle. Multidisciplinary feedback and letters to GPs resulted in some reduction in the number of patients prescribed benzodiazepines and Z-drugs. Ongoing educational strategies aimed at relevant health care workers with regular audit of medication use within the general hospital setting is pertinent to further improve prescribing practice.

Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety (NESDA)

AIM

Results on determinants of benzodiazepine (BZD) use in general and inappropriate use were inconsistent and mostly univariate. The relative importance of sociodemographic, psychological and physical determinants has never been investigated in a comprehensive, multivariate model.

METHODS

We included 429 BZD users and 2423 non-users from the Netherlands Study of Depression and Anxiety (NESDA) in order to investigate sociodemographic, psychological and physical determinants of BZD use and inappropriate use by logistic and linear regression analyses.

RESULTS

BZDs were used by a considerable proportion of the 2852 NESDA participants (15.0%). BZD use was independently associated with older age, singleness, unemployment, treatment in secondary care, higher medical consumption (more severe) anxiety, depression (OR [95% CI]=1.95 [1.29, 2.93]), comorbidity, insomnia, SSRI (OR [95% CI]=2.05 [1.55, 2.70]), TCA and other antidepressant (OR [95% CI]=2.44 [1.64, 3.62]) use. Overall, BZD use was rarely in accordance with all guidelines, mainly because most users (82.5%) exceeded the recommended duration of safe use. Inappropriate use was independently associated with older age (β=0.130) and chronic illnesses (β=0.120). Higher scores on agreeableness were associated with less inappropriate use.

CONCLUSIONS

Mentally or physically vulnerable subjects were most likely to use BZDs. The most vulnerable (i.e. the old and physically ill) BZD users were at highest risk of inappropriate BZD use. Without further evidence of the effectiveness of BZDs in long-term use, caution in initiating BZD prescriptions is recommended, particularly when patients are chronically ill and old, as those are most likely to display inappropriate use.

Chemical Dependency in the Elderly: Identification Phase

Selon les praticiens, la dépendence sur les produits chimiques chez les aînés est un problème sérieux qui va en s'aggravant. Cet article présente un compte rendu du programme Les aînés en santé, un programme pilote conçu pour étudier les problémes de conception de services à l'intention des aînés qui souffrent de dépendence envers les drogues. Le processus et les outils de sélection utilisés pour la stratégie de dépistage sont présentés. De plus, les résultats récents de l'analyse des données épidémiologiques recueillies à l'aide de ces outils de sélection sont mentionnés. Finalement, les conséquences de cette stratégie d'identification pour l'intervention, le traitement et les futures études de recherche sont examinées.

Usage of benzodiazepines: A review

Abstract Purpose. The use of benzodiazepines remains a source of controversy. Some prescribers believe that they are beneficial and espouse their use; others regard their risk:benefit ratio as too adverse for any but occasional use. This review considers these viewpoints based on the appropriate literature. Survey. The recent English-language literature relating to this topic was surveyed. The publications proved too heterogeneous for a formal meta-analysis, so a descriptive review is provided. Overview. Surveys of benzodiazepine use provide data mainly from the UK, Europe and North America. Prescribing patterns varied widely but long-term usage is common and sometimes the norm. Conclusions. Long-term prescription of benzodiazepines still takes place despite general warnings from the medical and other professions and drug regulatory bodies that long-term use is unjustified both from the lack of a systemic database establishing such efficacy and a large literature documenting the risks of long-term usage, such as dependence. The young and the old are particularly at risk. Continued monitoring is essential, but the regulatory authorities may need to take a more active role in curbing such undesirable practice.

General Practitioners reduced benzodiazepine prescriptions in an intervention study: a multilevel application

OBJECTIVE

This study investigated the effects of general practitioner, patient, and prescription characteristics on the reduction of long-term benzodiazepine prescribing by sending a letter to chronic users. The data were analyzed with a method respecting the hierarchical data structure.

STUDY DESIGN AND SETTING

Data were obtained from 8,170 chronic users nested in 147 general practices. One thousand two hundred fifty-six chronic users in 19 general practices received a letter with the advice to reduce or stop the use of benzodiazepines after the general practitioners had attended a course on benzodiazepine use. In a three-level random intercept multilevel regression model, long-term prescribing of benzodiazepines was the dependent variable.

RESULTS

The reduction in benzodiazepine prescribing was significantly larger in the intervention than in the control group: 16% after 6 months and 14% after 12 months, respectively. The age of the patient, gender, and the interaction between age and gender were significant. The combination of the duration (long acting or short acting) with the type of benzodiazepine (anxiolytic or hypnotic) was an important pharmacological baseline covariate.

CONCLUSIONS

The reduction of benzodiazepine prescribing was mainly explained by the letter intervention and individual patient characteristics. Multilevel analysis was a worthwhile method for application in this study with its unbalanced design.

Socioeconomic influences on benzodiazepine consumption in an Irish Region

Misuse of prescription sedatives is a significant problem for addiction treatment services. The aim of this study was to examine the prescribing of diazepam in disadvantaged Irish communities, and to identify factors which may predict diazepam consumption in that population. We examined prescribing trends for those aged 16-69 years in 2002 in a region of the state-funded General Medical Services Scheme. Material deprivation was based on the 2002 Small Area Health Research Unit (SAHRU) deprivation index. The average defined daily dose (DDD) was calculated and logistic regression analysis was used to predict diazepam use by age, gender and deprivation index. Results showed that patients living in the most-deprived areas were more likely to receive diazepam than patients living in the least-deprived areas (OR = 1.21, 95% CI 1.15-1.27). Female patients living in the most-deprived areas were also more likely to receive diazepam than those living in the least-deprived areas (OR = 1.36, 95% CI 1.18-1.57). It is concluded that there is a pattern of higher diazepam prescribing in areas of greatest deprivation, where prescription sedatives play a complex role within troubled families.

Cost of pharmacological care of the elderly: implications for healthcare resources

Expenditures on prescribed medicines are significantly higher among those aged 65 years and over than among younger people. As populations in developed countries age so the cost of pharmacological care associated with the older population can be expected to increase. While pharmacological care represents only one component of healthcare, its costs are increasing rapidly because of advances in technology and increasing use. However, such costs should be considered within a context of decreasing disability in the elderly population, improving economic conditions among seniors and the relationship of these costs with those in other aspects of healthcare. Where medications have been demonstrated to be cost-effective, attempts to curtail expenditure growth may prove a false economy resulting in significantly higher growth elsewhere such as in the hospital and long-term care sectors. Policy responses to this issue should encompass the inclusion of elderly patients in clinical trials, the use of evidence-based principles of practice and strategies to ensure that this population obtain maximum benefit from medication through education and counselling.

The population's use of pharmaceuticals

OBJECTIVES

In this study, population-based analysis is used to study the extent to which characteristics such as age, sex, socioeconomic status, and region of residence are associated with different patterns of pharmaceutical use. It also includes an examination of whether pharmaceutical use is responsive to differential health needs across the population.

RESEARCH DESIGN

Indicators of access, intensity of use, and total expenditures are used to describe Manitobans' use of pharmaceutical agents, consistent with the POPULIS framework.

MEASURES

Several rate-based measures have been developed for this purpose: the number of residents who are pharmaceutical users; the number of prescriptions dispensed; the number of different drugs dispensed; the total number of defined daily doses (DDDs) dispensed; and expenditures for pharmaceuticals. The DDD measurement provides a cumulative assessment of total drug use (i.e., across multiple drug categories) and is a useful indicator of a population's total drug exposure.

RESULTS

Patterns of use of pharmaceuticals follow patterns similar to those patterns in earlier POPULIS studies on health care access, intensity, and expenditures. In areas where health is generally poorer, a greater number of prescriptions are dispensed. The highest use of pharmaceuticals also was found in the lower-income quintiles and among those at greatest socioeconomic risk, traditionally those with the poorest health status.

CONCLUSIONS

This kind of population-based pharmaceutical information can help monitor the effectiveness of policy initiatives, as well as serve to better manage pharmaceutical use within the health care system.

Correlates and prevalence of benzodiazepine use in community-dwelling elderly

OBJECTIVE

To describe the prevalence of benzodiazepine use, sociodemographic and physical health factors associated with use, dosages taken, and directions for use among individuals aged 65 years and older.

DESIGN

Cross-sectional analysis of baseline data from the community-based, prospective observational Cardiovascular Health Study.

PATIENTS/PARTICIPANTS

Medicare eligibility lists from four U.S. communities were used to recruit a representative sample of 5,201 community-dwelling elderly, of which 5,181 participants met all study criteria.

MEASUREMENTS AND MAIN RESULTS

Among participants, 511 (9.9%) were taking at least one benzodiazepine, primarily anxiolytics (73%). Benzodiazepines were often prescribed to be taken pro re nata (PRN "as needed"), and 36.5% of prescriptions with instructions to be taken regularly were taken at a dose lower than prescribed. Reported over-the-counter (OTC) sleep aid medication use was 39.2% in benzodiazepine users and 3.3% in nonusers. In a multivariate logistic model, the significant independent correlates of benzodiazepine use were being white (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.0, 3.4), female (OR 1.7; CI 1.4, 2.2), and living in Forsyth County, North Carolina, or Washington County, Maryland, compared with living in Sacramento County, California, or Allegheny County, Pennsylvania (OR 2.3; CI 1.4, 2.2); having coronary heart disease (OR 1.6; CI 1.2, 2.1), health status reported as poor or fair (OR 1.8; CI 1.4, 2.3), self-reported diagnosis of nervous or emotional disorder (OR 6.7; CI 5.1, 8.7), and reporting use of an OTC sleep aid medication (OR 18.7; CI 14.1, 24.7).

CONCLUSIONS

One in 10 participants reported taking a benzodiazepine, most frequently an anxiolytic, often at a lower dose than prescribed and usually PRN. The high prevalence of OTC sleep aid medication and benzodiazepine use may place the patient at increased risk of psychomotor impairment. Physicians should assess OTC sleep aid medication use when prescribing benzodiazepines.

Psychopharmacoepidemiology in Iceland: effects of regulations and new medications

The sale of psychotropic medications in Iceland has waxed and waned during the past 20 years with approximately 5 years between peak and bottom quantities sold. Apparently, it has decreased following restrictions imposed by the public health authorities and increased again following the introduction of new drug. In order to study this further, all prescriptions for psychotropic medications to non-hospitalized inhabitants of the capital city (Reykjavík) and dispensed by pharmacists there during 1 month in 1984, 1989 and 1993 were analysed in order to estimate the 1-month prevalence of psychopharmacological use. The results support the hypothesis partly as prescriptions for tranquillizers decreased in 1989 as well as the amount of tranquillizers and hypnotics prescribed following new restrictions, whereas the prevalence odds ratio of obtaining prescriptions for hypnotics remained unchanged. The proportion of patients receiving excessive amounts of tranquillizers and/or hypnotics decreased. The prevalence of excessive use of these drugs (i.e. > 90 DDD/month) was 0.5% in 1993. In 1993 the prevalence of the use of antidepressants as well as the amount prescribed had increased substantially following the introduction of the new selective serotonin reuptake inhibitor medications. Thus, the prevalence of patients obtaining any psychotropic medication remained unchanged from 1984 to 1993.

Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research

OBJECTIVE

A randomised, controlled clinical trial was performed to study the long-term effect of gradual withdrawal from benzodiazepines on the daily functioning of residents of homes for the elderly. The planned sample size was not achieved due to recruitment and follow-up problems.

RESULTS

The results in this small sample nevertheless suggest that gradual withdrawal from benzodiazepines is possible in residents of homes for the elderly, and that it can have a positive effect on their daily functioning. No major withdrawal symptoms were observed, although there was a decrease in sleep quality during withdrawal.

CONCLUSION

The findings are promising for further research, but researchers should anticipate the problems inherent in executing a trial with institutionalised elderly subjects.

Hypnotic drug use in Spain: a cross-sectional study based on a network of community pharmacies. Spanish Group for the Study of Hypnotic Drug Utilization

OBJECTIVE

To investigate how hypnotic drugs are used in Spain, specifically, (1) to characterize the user population in some simple demographic (e.g., sex, age) and clinical (e.g., type of insomnia, type of physician who prescribed the drug) variables; (2) to estimate the proportion of long-term users (> 3 mo); (3) to determine the frequency of different administration schedules; (4) to determine whether the kind of hypnotic drug prescribed according to the duration of its effect correlates with the type of sleep disorder or patient age; and (5) to compare the dosage used by the elderly with that used by adults.

DESIGN

Cross-sectional pharmacy-based study.

SETTING

A network of 318 community pharmacies throughout Spain.

SUBJECTS

Patients (n = 5324) requesting a hypnotic drug for insomnia who agreed to take part in the study.

MAIN OUTCOME MEASURES

Distribution of the use of hypnotic drugs by age, sex, type of insomnia, type of physician, specific hypnotic drug, daily dosage, treatment schedule, and duration of treatment.

RESULTS

Women (67%) and the elderly (58%) constituted the largest subgroups in the sample. Difficulties in sleep onset and in sleep maintenance as single disorders were reported by 38% and 37% of users, respectively. Prescriptions were written by general practitioners in 80% of cases. Daily use was reported by 88% and long-term use (> 3 mo) by 72% of the users. Long-term treatment was two- to threefold more frequent in the elderly than in middle-aged subjects. Intermediate-action hypnotic drugs were used by 59% of subjects, short-action drug by 24%, and long-action drugs by 17%. The type of hypnotic drug prescribed was not related to the kind of sleep disorder or the age of patients. Specialists prescribed long-action hypnotic drugs more often than did general practitioners. No relevant differences were observed between dosages used by the elderly and those used by adults. In both groups the dosage taken by most patients, regardless of the drug, corresponded to the available strength. Substitution drugs for triazolam belonged to the intermediate-action class in 53% of the cases.

CONCLUSIONS

Recommendations on hypnotic drug use are largely not followed in Spain. Most patients are taking hypnotic drugs daily, over long time periods, and without an adequate dosage titration according to age. Measures should be taken to correct this situation.

Predictors of chronic benzodiazepine use in a health maintenance organization sample

While expert recommendations caution against long-term benzodiazepine use in the elderly, survey data suggest increasing benzodiazepine use with age. Computerized pharmacy records of staff-model HMO were used to examine benzodiazepine prescribing. Six-month prevalence of benzodiazepine use (2.8%) and prevalence of continued use (0.7%) were lower than earlier reports. Prevalence was higher in women and increased steadily with age. Among 7012 patients beginning benzodiazepine treatment, duration of use increased with patient age, prescription by a psychiatrist (vs. primary care or medical/surgical specialist), use of higher-potency drugs (lorazepam, and alprazolem, clonazepam) and larger number of pills in the initial prescription. Individual physicians varied significantly in drug choice, initial prescription size, and likelihood of chronic use. Among 200 patients treated in primary care, the physician-recorded indication for prescription was anxiety or depression in 27%, insomnia in 20%, and pain symptoms in 38%. These findings indicate a gap between benzodiazepine efficacy research and current clinical practice.

Benzodiazepine use among elderly patients presenting at the emergency room

This study evaluated the prevalence of benzodiazepine intake by elderly patients presenting at the emergency room of a university hospital. Of 388 patients, 42.5% used one or more benzodiazepine (BZD) drugs in the week prior to admission. There were significantly more women among the BZD users (P < 0.05). Mean duration of intake was long (62 months), but daily dosage was adjusted to age. Of the BZD using patients, 27% took a BZD with long elimination half life. No relationship was found between the BZD intake and the occurrence of falls. Fallers were significantly older (P = 0.019) and were more often women (P = 0.046).

Misuse of prescription drugs

The elderly person is at risk of drug misuse and related problems because of frequent use of prescription drugs, biologic factors, and social circumstances associated with aging. Confusion, falls, and aggravation of untoward emotional states are examples of the adverse consequences. Diagnosis of drug dependency states is difficult because of the overlap of general medical disorders and mental disorders and a lack of suitable diagnostic criteria for the aged. Two case examples of drug misuse are given, and the management of drug misuse and the treatment of drug dependence on an inpatient and outpatient basis are discussed. Future research directions are suggested.

Insomnia and psychotropic drug consumption

1. During an epidemiological study conducted by telephone on sleep disorders in the metropolitan area of Montreal (Quebec, Canada), the authors found that 5% of subjects used psychotropic drugs. These drugs were usually prescribed by a general practitioner (72.9%). 2. From this population, the authors drew three groups of subjects: users with sleeping difficulties (USD); non users with sleeping difficulties (NUSD) and, non users without sleeping difficulties (NUWSD). 3. Results showed that the utilization of psychotropics was usually chronic and more frequent among the elderly and women. 4. In multivariate models, when users were compared to NUWSD, the authors found eight variables significantly associated with psychotropic consumption: age (> or = 55), sex (female), presence of physical illness, medical consultation, dissatisfaction with sleep onset period and sleep quantity, sleep onset period greater than 15 minutes, and to never or rarely dream. 5. When users were compared to NUSD, three variables were found to be associated with psychotropic consumption: age, to be formerly married, and to experience regular nighttime awakenings. 6. It appears that the utilization of psychotropic drugs does not increase the quality of sleep when consumers are compared to non treated insomniacs (NUSD) on parameters of sleep satisfaction.

Sleep quality and the use of benzodiazepine hypnotics in general practice

The aim of the study was to determine the usage patterns of benzodiazepine hypnotics, the use of other ways of improving sleep and general sleep characteristics in patients prescribed these drugs on a regular basis and in a control group of age- and sex-matched patients not receiving hypnotics. Patients receiving regular benzodiazepine hypnotic prescriptions and a control group matched for age and sex were identified from a general practice computer. They were interviewed in their own homes about their habits relating to sleep, hypnotic use and attitudes to sleep and hypnotics. None of the recommended methods of improving sleep differed significantly in frequency between the two groups or had an effect on sleep parameters. Only daytime napping was found to be slightly more frequent in hypnotic users, but had no apparent effect on self-estimates of sleep duration or latency. The hypnotic users claimed a longer sleep latency and a shorter sleep duration than non-users. More patients who took hypnotics also perceived them to be beneficial and more convenient than other ways of promoting sleep. The recommendation of sleep-promoting methods such as caffeine and alcohol avoidance and regular exercise may not be helpful in patients attempting to avoid hypnotics, as many patients already claim to use such methods.

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

Sex differences among recipients of benzodiazepines in Dutch general practice

OBJECTIVE

To analyse sex differences among recipients of benzodiazepines in Dutch general practice.

DESIGN

Study of consultations and associated interventions as recorded in the Dutch national survey of general practice.

SETTING

Practices of 45 general practitioners monitored during 1 April to 30 June 1987.

SUBJECTS

61,249 patients (29,035 (47.4%) men in the age groups 19-44, 45-64, and 65 years and over.

MAIN OUTCOME MEASURES

Symptoms among recipients of repeat as well as new benzodiazepine prescriptions stratified by sex and age.

RESULTS

Prescriptions for benzodiazepines were found to be significantly more common among women than among men, (a) after correcting for the sex distribution of the total patient population, and (b) in the two oldest age groups after correcting for the number of consultations. Of all prescriptions for benzodiazepines, 89% (6055/6777) were repeats and 70% (4759/6777) requests. Only 9% (439/4759) of these were authorized by the general practitioner, the rest being issued by the general practitioner's assistant after he or she had referred to the diagnosis in the patient's record. In contrast, only three (1%) of the 492 first time recipients of benzodiazepines had requested a prescription and were not seen by the general practitioner. Women (43/96; 45%) aged 45-64 years received their first prescription for benzodiazepines almost twice as often as men (15/63; 24%) without symptoms or a diagnosis being an indication (female to male relative risk 1.88 (95% confidence interval 1.15 to 3.08)).

CONCLUSIONS

The sex difference among first time recipients of benzodiazepines seems to be due to general practitioners being less stringent when prescribing this drug for women. The difference continues in repeat prescriptions, physicians failing to check adequately the need for these.

Are patterns of benzodiazepine use predictable? A follow-up study of benzodiazepine users

A sample of 171 patients taking benzodiazepines (BZDs) who had been investigated in 1988 was followed up in 1991. From 140 patients who were still alive and willing to participate, 25% had stopped BZDs after an average duration of intake of 34 months. Of the 105 persons still taking a BZD, 37% were taking the same dose, 26% had reduced the dose and 37% had increased it. Characteristics of BZD long-term users and patients potentially at risk for abuse and/or dependence that were established from the 1988 data were reexamined: patients with continued BZD use more often suffered from somatic illness which often had deteriorated, they had a longer duration of intake and used higher daily doses. In most cases the indication was insomnia. Patients with a clinically relevant dose increase were more often males, frequently found to be dependent on alcohol and/or illegal drugs.

Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers

A sample of 171 benzodiazepine (bzd) users was investigated in the pharmacy where the patients filled in their prescriptions. Of the sample, 29.8% were males and 70.2% were females. About 60% of the patients had their current prescription from a general practitioner, the rest from different specialists. 70.8% stated to take bzds on more than 3 days of the week. The mean duration of intake of the entire sample was 4.5 years. The most frequent reasons for bzd intake were sleep disturbance followed by nervousness and somatic diseases. A total of 74.9% of the patients turned out to be well informed about the potential dependence hazards of bzd long term intake, but less than half of them had been informed by the prescribing physician. In a second step it could be demonstrated by means of multiple stepwise logistic regression analysis that certain characteristic parameters differentiate long-term users and persons with signs of potential abuse and dependence from other bzd users.

Failure to limit quantities of benzodiazepine hypnotic drugs for outpatients: placing the elderly at risk

PURPOSE

The long-term use of benzodiazepine hypnotics by the elderly is associated with serious side effects, and prescriptions of large quantities of these agents allow such use. Therefore, we determined the quantities of these agents prescribed to outpatients in our Veterans Administration teaching hospital, and the relationship of patient age to total number of doses prescribed per prescription.

PATIENTS AND METHODS

Pharmacy and patient records related to 655 consecutive prescriptions for triazolam (Halcion) and flurazepam (Dalmane) were reviewed. Only 266 (41%) of the prescriptions were for 30 or fewer doses, while 178 (27%) were written for 180 or more doses.

RESULTS

Thirty-six percent of prescriptions for patients aged 65 years or older were for 180 or more doses, compared with 24% for those aged 45 to 64 years old, and 16% of the prescriptions for patients less than 45 years old (p less than 0.0001). In a multivariate analysis controlling for six other factors related to the total number of doses prescribed, patients aged 65 years or older were still more likely to receive a prescription for 180 or more doses (relative risk 1.9, 95% confidence interval 1.3, 2.8).

CONCLUSION

We conclude that inappropriately large quantities of benzodiazepine hypnotics were commonly prescribed, and that patients aged 65 years or older were at greatest risk for receiving such prescriptions.

[General practitioners and internists prescribe psychopharmaceutic drugs]

An epidemiological study using data from a local German health insurance fund on the psychotropic drug prescription of physicians and the drug utilisation of their patients is presented. Taking a sample of 280 out-patients, descriptive methods are presented (defined daily dose (DDD), prescribed daily dose (PDD), active-agent-oriented classification of drugs, therapy-oriented classification of diagnoses). The following questions are answered by this study: Which patients with which indication received which dosage of which psychotropic drug for how long from which physicians? The patient-based structure of the data, taking into account the prescriptions of all physicians allows the course of therapies and the study of overall psychotropic medication. Prevalences estimates concerning the patients are also possible. Our results are compared with those of similar pharmaco-epidemiological studies; the difference in prevalence estimates, as well as advantages and possible disadvantages arising from the use of such secondary data base, are discussed.