Mental Health and Disability Pension Onset: Changes in Consumption of Antianxiety and Hypnotic Drugs

Introduction:

In Norway, disability pension (DP) has been more prevalent over the later years, with mental disorders being a frequent cause. Previous analyses have questioned whether receiving DP is beneficial for mental health by considering changes in antidepressant drug consumption. To explore this further, we examined changes in antianxiety and hypnotic drug consumption following DP onset.

Methods:

Based on national Norwegian register data, this retrospective study encompassed 8617 working-age individuals (25-50 years) who became DP during 2005 to 2013. We compared their benzodiazepines (BZD) and Z-hypnotic consumption 1 year pre- and postdisability pension onset.

Results:

About 80% of the individuals did not change their altogether benzodiazepine/Z-hypnotic consumption. Among individuals with an initial consumption ≤1 defined daily dose (DDD), 18.9% increased their consumption to above 1 DDD. Individuals in the age-group 45 to 50 versus 24 to 34 years had a lower risk of dose escalation (odds ratio [OR], 0.756, 95% confidence interval [CI]: 0.601-0.957). Individuals who used Z-hypnotics only had a higher risk of dose escalation compared to the joint benzodiazepine/Z-hypnotic user group (OR, 1.594, 95%CI: 1.284-1.970).

Conclusion:

In general, we cannot see that DP is associated with changes in benzodiazepine/Z-hypnotic consumption, but younger users and individuals using Z-hypnotics only had a greater risk of dose escalation compared to the older users and users with combined BZD and Z-hypnotic use.

New benzodiazepine and Z-hypnotic users and disability pension: an eight-year nationwide observational follow-up study

OBJECTIVE

To compare how newly initiated treatment with benzodiazepines, Z-hypnotics or both associates with the reception of disability pension among 40,661 individuals of a working age.

DESIGN

Prescription register study.

SETTING

Norwegian nationwide prescriptions socio-economic and disability status data.

METHODS

Cox regression analyses.

SUBJECTS

New benzodiazepine or Z-hypnotic users.

MAIN OUTCOME MEASURE

Time to receive disability pension given benzodiazepine or Z-hypnotic use or both. Additional analyses focused on the benzodiazepine first redeemed.

RESULTS

Among new users 8.65% of Z-hypnotic users, 12.29% of benzodiazepines users and 13.96% of combined Z-hypnotic and benzodiazepine users became disability pensioners. Z-hypnotic users were weaker associated with becoming disability pensioners (HR = 0.78, CI: 0.73-0.84) and combined users were stronger associated (HR = 1.09, CI: 1.01-1.17), than benzodiazepine users. Women had higher risk than men for becoming disability pensioners. Higher age, lower education, previous drug use and psychiatrist as first prescriber were risk factors. Comparing first benzodiazepine redeemed; clonazepam initiators were stronger associated with becoming disability pensioners than diazepam initiators were (HR = 2.22, CI: 1.81-2.71). No differences between other benzodiazepine users were found.

CONCLUSIONS

Adjusting for known risk factors gave lower risk for Z-hypnotic users compared to benzodiazepine users for receiving disability pension. Combined use increased the risk further. Clonazepam initiators are especially at risk. These findings may be helpful in prescribing situations to identify and guide individuals at risk for becoming disability pensioners.

Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway

OBJECTIVE

To identify risk factors for becoming an excessive user over time.

SETTING

Prescription database study over five years.

SUBJECTS AND METHOD

Norwegians between 30 and 60 years with a first dispensation of a benzodiazepine during 2006, encompassing 23 227 individuals. A Cox hazard regression model was defined, initially stratifying on gender, age, county, previous relevant drug dispensations, household income, education level, and vocational rehabilitation support.

MAIN OUTCOME MEASURE

The time from the first redemption until excessive use was defined as using more than two DDDs per day on average within a three-month period.

RESULTS

Women's risk was lower than men's for excessive use (HR = 0.42, CI 0.35-0.51). Initial oxazepam, alprazolam, or nitrazepam/flunitrazepam use indicated higher risk compared with diazepam (HR = 1.51, CI 1.24-1.85, HR = 2.75, CI 1.54-4.91, HR = 1.67, CI 1.29-2.16). Previous antidepressants or lithium, antipsychotics or opioids, anti-alcohol and smoke cessation treatment indicated a higher risk compared with no such use (HR = 1.4, CI 1.16-1.69, HR = 1.92, CI 1.54-2.4, and HR = 2.88, CI 2-4.15). Higher education and average or high household income were associated with a low risk compared with low education and income (HR = 0.68, CI 0.57-0.81, HR = 0.58, CI 0.46-0.73, and HR = 0.37, CI 0.26-0.54). Working in the private or public sector was associated with a low risk compared with no registered work (HR = 0.53, CI 0.4-0.71 and HR = 0.57, CI 0.45-0.74).

CONCLUSION

The prevalence of excessive use over a five-year observation period was 2.34%. Risk factors were indications of psychiatric illness, first benzodiazepine choice, low income, and education. Excessive users were also characterized by a more severe disease, indicated by having prescription fulfilments by a psychiatrist and by switching benzodiazepines. Key points Guidelines state that benzodiazepines should be used for a short time and excessive use indicates drug dependency. Of all new benzodiazepine users 2.34% became excessive users, defined as consuming above two defined daily doses (DDDs) per day on average over three months, within a five-year period. Previous use of other psychotropic drugs, opioids and anti-alcohol and smoke cessation drugs, first benzodiazepine prescribed, low household income, and low education were risk factors for excessive use. Excessive users were characterized by switching benzodiazepines and having prescription fulfilments by a psychiatrist suggesting a more severe disease.

A 3-year survey quantifying the risk of dose escalation of benzodiazepines and congeners to identify risk factors to aid doctors to more rationale prescribing

OBJECTIVES

This study investigated and quantified risk factors of dose escalation, as an indication of drug misuse and dependency of benzodiazepines and congeners, among presumably drug naïve patients in the Norwegian drug prescription database, observed over 3 years.

DESIGN

Observational study.

SETTING

Prescription database study.

PARTICIPANTS

We defined an excessive user as one redeeming more than two defined daily doses per day in 3 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

We examined the risk of excessive use over time and the effect of risk factors through multistate logistic regression and scenarios.

RESULTS

Most of the 81 945 patients had zopiclone or zolpidem as the initial drug (63.8%), followed by diazepam (25.3%), oxazepam (6.1%), nitrazepam/flunitrazepam (2.9%), hydroxyzine/buspirone (1.6%) and alprazolam (0.3%). At any time 23% redeemed prescriptions, about 34% did not redeem any prescriptions beyond any 3-month period and 0.9% ended up as excessive users. Patients previously using drugs, such as opioids, antialcohol or smoke cessation treatment, had a higher risk to become excessive users compared to patients who had not. Patients whose first prescription was for oxazepam or nitrazepam/flunitrazepam had a higher risk of becoming an excessive user compared to those who started with diazepam. A specialist in general practice as the first-time prescriber was associated with a lower risk compared to doctors without specialty.

CONCLUSIONS

Most benzodiazepine use occurred according to guidelines. Still, some experienced dose escalation over time, and risk factors were previous use of other psychotropic drugs, long time use, choice of first-time drug and prescriber's specialty. This could incite doctors to have a cessation plan when issuing first-time prescriptions.

Pharmacologically inappropriate prescriptions for elderly patients in general practice: How common? Baseline data from The Prescription Peer Academic Detailing (Rx-PAD) study

OBJECTIVE

To assess Norwegian general practitioners' (GPs') level of potentially harmful drug prescribing for elderly patients.

DESIGN

Prescription data for 12 months were retrospectively retrieved from the Norwegian Prescription Database (NorPD). Data were assessed in relation to 13 prescription quality indicators.

SETTING

General practice.

SUBJECTS

A total of 454 GPs attending continuous medical education (CME) groups in Southern Norway, 85,836 patients >or=70 years who received any prescription from the GPs during the study period.

MAIN OUTCOME MEASURES

Number of prescriptions assessed in relation to pharmacological inappropriateness based on a list of 13 explicit prescription quality indicators.

RESULTS

Some 18.4% of the patients (66% females with mean age 79.8 years, 34% males with mean age 78.7 years) received one or more inappropriate prescriptions from their GP. An NSAID in a potentially harmful combination with another drug (7%) and a long-acting benzodiazepine (4.6%) were the most frequent inappropriate prescriptions made. Doctor characteristics associated with more inappropriate prescribing practice were old age and working single-handed with many elderly patients.

CONCLUSION

The study reveals areas where GPs' prescribing practice for elderly patients can be improved and which can be targeted in educational interventions.

[The good discharge summary--criteria and evaluation]

BACKGROUND

A discharge summary should be sent to the primary care physicians to ensure adequate follow-up of patients after discharge from hospital. It should arrive in due time and its content should serve its purpose.

MATERIAL AND METHODS

We identified six criteria to be used for quality evaluation of discharge summary content and format. Two general practitioners and two hospital physicians applied the criteria in an evaluation of 50 consecutive discharge summaries from a department of internal medicine. The six criteria were given a score from 1 to 4 for each discharge summary.

RESULTS AND INTERPRETATION

The scores showed only a modest inter-rater agreement between the four evaluators. The hospital physicians tended to give higher scores than primary care physicians. The inter-rater agreement was best for information about medicines (mean weighted kappa 0.17) and ortograhy (mean weighted kappa 0.13). Collectively, the evaluators judged the discharge summaries to be of overall fair to good quality, although 44% of the summaries were given a poor score for at least one criterion. We suggest ways to ensure high quality content in discharge summaries.

Factors associated with high prescribing of benzodiazepines and minor opiates. A survey among general practitioners in Norway

OBJECTIVE

To determine the factors associated with high-volume prescribing of benzodiazepines and minor opiates--background characteristics, personal prescribing habits and general attitudes to prescribing.

DESIGN

A questionnaire survey. Descriptive statistics, bivariate analysis and multiple logistic regression.

SETTING

General practitioners in Norway.

SUBJECTS

Every third general practitioner from the list of members of the Norwegian Medical Association.

MAIN OUTCOME MEASURES

Odds ratios for being a high prescriber.

RESULTS

The main predictors of high-volume prescribing were: patients allowed to influence prescribing decisions, benzodiazepines and minor opiates prescribed without consultation, prescribing perceived as difficult and the doctor being male.

CONCLUSION

Emotional and relational aspects play an important part in decisions on prescribing benzodiazepine and minor opiates. Our findings indicate that there is potential for improvement in prescribing practice; for instance, by investigating how and to what extent prescribing decisions are influenced by patients and how the difficulties experienced influence the decision process. Better practice routines could be considered such as not prescribing these drugs without consultation.