An Approach to Reduce Benzodiazepine and Cyclopyrrolone Use in General Practice

Abstract

The global use of benzodiazepines and cyclopyrrolones is generally high. The hypnotic and anxiolytic effects of these agents typically diminish after a period of weeks or months of continuous use. Patients may thus be caught in a trap where the usefulness of these substances is reduced and doses are consequentially escalated, and where a subsequent phased reduction in dose can be difficult. Although considerable resources have been expended on reducing the use of these agents, no unambiguous and effective method has been identified.In Denmark, it is estimated that there are approximately 100 000 benzodiazepine-dependent patients, constituting approximately 2% of the general population. The prescription of dependency-producing drugs (including benzodiazepine/cyclopyrrolone agents) in Denmark is regulated according to Danish directive CIR nr 12, introduced on 13 January 2003, which aimed for restrictions in the prescribing of benzodiazepine and cyclopyrrolone drugs while setting revised guidelines for the re-evaluation of these agents. However, by 2004, the use of these drugs had decreased by only 1.7%, far from the official objective of a 50% reduction. This article describes an effective strategy implemented in general practice in Denmark to reduce the use of benzodiazepine and cyclopyrrolone agents, while at the same time challenging practitioners' ingrained habits and prejudices in this field. An intervention involving new regulations for the prescription of benzodiazepines and cyclopyrrolones was introduced to ten Danish medical practices, comprising 13 medical practitioners and a patient base of approximately 18 500 patients. The new intervention was essentially in accordance with the official Danish regulations, such that a prescription for benzodiazepines and cyclopyrrolones could only be issued for 1 month at a time, and only following consultation. Telephone prescriptions were eliminated. Use was monitored using the Danish registration system, Ordiprax, which monitors sales of prescription medicine. All users of benzodiazepines and cyclopyrrolones within the ten practices, with the exception of seriously psychiatrically and physically ill patients, were included. Fifteen months after the inception of the intervention, the use of cyclopyrrolones was reduced by 50.3%. Use of benzodiazepine-hypnotics was reduced by 46.5% and use of benzodiazepine-anxiolytics was reduced by 41.7%. The reorganisation of prescription patterns proved to be significantly easier than practitioners had expected. During the first 3 months, only 4.3 additional consultations per week per 1000 patients were required. Subsequently, this number fell to 2.1 additional consultations. The usual collaborative partners, such as psychiatrists, homecare services, hospitals and substance abuse units, were essentially not deployed. No serious side effects developed in patients in whom drug use was reduced. The intervention was effective in reducing the use of benzodiazepine and cyclopyrrolone agents in general practices in a large municipality in Denmark. It is recommended that this intervention be introduced into the primary care sector, as it requires minimal effort on the part of the medical practitioner. The intervention is as simple as it is effective, and its implementation does not require any major level of supplementary training.