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

ObjectivesThis 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.DesignObservational study.SettingPrescription database study.ParticipantsWe defined an excessive user as one redeeming more than two defined daily doses per day in 3 months.Primary and secondary outcome measuresWe examined the risk of excessive use over time and the effect of risk factors through multistate logistic regression and scenarios.ResultsMost 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.ConclusionsMost 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.

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 pointsGuidelines 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.

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.

BackgroundDrug 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.