Trine Bjørner

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 ≥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.

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

Objective r - r 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 r - r A questionnaire survey. Descriptive statistics, bivariate analysis and multiple logistic regression. Setting r - r General practitioners in Norway. Subjects r - r Every third general practitioner from the list of members of the Norwegian Medical Association. Main outcome measures r - r Odds ratios for being a high prescriber. Results r - r 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 r - r 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.

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 prescribers specialty. This could incite doctors to have a cessation plan when issuing first-time prescriptions.

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

Abstract 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.

[Dispensing of benzodiazepines and Z drugs by Norwegian pharmacies 2004-2011].

BACKGROUND In Norway, total sales of benzodiazepines and Z drugs (zopiclone and zolpidem) have increased since the mid-1990s. On the basis of data from the Norwegian Prescription Database, we have studied the choice of medications and patterns of use in various gender and age groups. MATERIAL AND METHOD Numbers for redemptions of benzodiazepines and Z drugs in Norwegian pharmacies for the years 2004-2011 were collected from the Prescription Registry. Population figures were collected from Statistics Norway. Consumption was calculated by the number of DDDs (defined daily doses). RESULTS Among those who were supplied with benzodiazepines or Z drugs, recipients of more than 2 DDDs per day (heavy users) accounted for a small group. We registered an extensive use of Z drugs among older women, many of whom were prescribed an amount corresponding to a regular daily use of 1-2 DDDs. The total prescription of alprazolam and nitrazepam/flunitrazepam was minor, but high dosages were not uncommon among those who were prescribed these drugs. Only a small proportion of the patients who were prescribed clonazepam received a reimbursable prescription. The prescribing of a number of benzodiazepines and Z drugs at the same time remains not uncommon. INTERPRETATION Prescribing of Z drugs to the elderly, and to women in particular, may indicate that many people in this group are regular users of sedative hypnotics, which is contrary to the guidelines. A considerable proportion of the prescriptions for clonazepam are outside of the approved indications. Among the users of the drugs studied, only a small fraction were heavy users, but since the use is widespread, this represents a considerable number of individuals.

Use of forms for follow-up of diabetes in general practice.

BACKGROUND The majority of patients with type 2 diabetes are followed up in general practice. We have investigated whether the use of forms by GPs for recording clinical data contributes to lower mortality and morbidity for this patient group. MATERIAL AND METHOD This systematic review is based on literature searches in MEDLINE, EMBASE, ISI Web of Science, Cochrane CENTRAL and PubMed. We included studies that 1) dealt with adults over 18 years of age with diabetes who were followed up in the primary health service and 2) compared mortality and morbidity with and without the use of forms. We summarised the results qualitatively and using meta-analyses. RESULTS Seven studies were included. One study (1262 participants) investigated the effect of the form on hard endpoints, without finding clear effects on mortality (HR 0.91; 95% CI 0.72-1.14), retinopathy (OR 0.90; 95% CI 0.53-1.52), peripheral nerve injury (OR 0.86; 95% CI 0.57-1.29), myocardial infarction (OR 0.65; 95% CI 0.31-1.35) or stroke (OR 0.89; 95% CI 0.39-2.01). Use of forms appears to have little or no effect on body weight (3 studies), and a small, positive effect on blood pressure (5 studies) and total cholesterol (2 studies). INTERPRETATION Published data at present provide no clear answers, but shows that use of forms in the follow-up of patients with diabetes in general practice may tend to contribute to lower mortality and morbidity.

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

Abstract 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.

A 5-year follow-up study of users of benzodiazepine: starting with diazepam versus oxazepam

BACKGROUND Drug dependency may develop during long-term benzodiazepine use, indicated, for example, by dose escalation. The first benzodiazepine chosen may affect the risk of dose escalation. AIM To detect possible differences in benzodiazepine use between new users of diazepam and oxazepam over time. DESIGN AND SETTING This 5-year prescription database study included 19 747 new benzodiazepine users, inhabitants of Norway, aged 30-60 years, with first redemption for diazepam or oxazepam. METHOD Individuals starting on diazepam versus oxazepam were analysed by logistic regression with sex, age, other drug redemptions, prescribers specialty, household income, education level, type of work, and vocational rehabilitation support as background variables. Time to reach a daily average intake of ≥1 defined daily doses (DDD) over a 3-month period was analysed using a Cox proportional hazard regression model. RESULTS New users of oxazepam had a higher risk for dose escalation compared with new users of diazepam. This was true even when accounting for differences in sociodemographic status and previous drug use (hazard ratio [HR] 1.33, 95% confidence interval = 1.17 to 1.51). CONCLUSION Most doctors prescribed, according to recommendations, oxazepam to individuals they may have regarded as prone to and at risk of dependency. However, these individuals were at higher risk for dose escalation even when accounting for differences in sociodemographic status and previous drug use. Differences between the two user groups could be explained by different preferences for starting drug, DDD for oxazepam being possibly too low, and some unaccounted differences in illness.