RESEARCH – September 2020

Benzodiazepine and Z-drug use in ambulatory care in Estonia

Authors: Katrin Kurvits, Maia Uusküla, Ott Laius, Peeter Jaanson

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Benzodiazepines and related drugs (Z-drugs) have been used for decades for the treatment of various conditions, mainly to treat anxiety and insomnia. Guidelines emphasise that benzodiazepines and Z-drugs should only be used short term, as tolerance and dependence may develop with prolonged use. In addition, their use has been associated with cognitive and psychomotor impairment leading to injuries and traffic accidents. It is recommended to avoid using benzodiazepines and Z-drugs in the elderly, as they are more susceptible to the adverse effects. The aim of this study was to describe the prevalence of benzodiazepine and Z-drug use in Estonia among different age groups, also to analyse current restrictions on benzodiazepine and Z-drug use and the need for revision of these restrictions. We retrieved prescriptions of insured benzodiazepine and Z-drug users for the period of November 2018 – October 2019 from the Estonian Health Insurance Fund’s prescription centre. The annual age- and sex-specific prevalence rates were calculated using population at January 1st 2019. Long-term use was defined as drug consumption of at least 180 defined daily doses (DDD) per year, consumption more than 1000 DDDs were considered as highdose use. Amount purchased was evaluated in respect of the maximum quantity per prescription. Swedish and Danish ambulatory care consumption data and population data were used for comparison. During the study period the prevalence of benzodiazepine and Z-drug use was 101 per 1000 inhabitants (n=134 007). The prevalence increased with age – the use was 2-3 times more common in the elderly compared to users aged 25-64. Women used benzodiazepines and z-drugs twice as often as men. Majority (72%) of benzodiazepine and z-drug prescriptions were prescribed by general practitioners, followed by psychiatrists (19%) and neurologists (1%). Benzodiazepines and z-drugs were mainly prescribed for sleep disorders (43%), anxiety disorders (14%) and depression (14%). 21% of all benzodiazepine and z-drug users were long-term users. Long-term use was more common in the elderly. There were 482 (0.4%) high-dose users. In majority of prescriptions, the maximum or more than half of the maximum (respectively 41% and 40% of prescriptions) of the quantity allowed to be dispensed with one prescription was purchased. Slightly more than half (54%) of the users had purchased one or two prescriptions, 41% had 3-12 prescriptions and 5% had more than 12 prescriptions during the one-year study period. The usage 3-12 prescriptions per year was more common among the very elderly (≥ 85) compared to younger users. Of the users with more than 12 prescriptions, 36% had prescriptions from three or four different doctors and 11% from five or more different doctors. The prevalence of benzodiazepine anxiolytics and clonazepam use was two to three times more common in Estonia compared to Swedish and Danish population. The usage of Z-drugs in Estonia was at the same level as in Sweden, but in Denmark the use was almost twofold lower. In conclusion, the usage of benzodiazepines and Z-drugs is relatively common in Estonia. Although the elderly are known to be most at risk of adverse reactions, the usage is most common in this age group. Benzodiazepines and Z-drugs were often prescribed in the maximum quantity allowed and there were users receiving prescriptions inappropriately frequently and from several doctors. Consequently, the regulations of benzodiazepines and Z-drugs should be revised. The Estonian digital prescription system allows developing patient-based warnings and restrictions to promote rational use. Clinical indicators should be developed to monitor the usage of benzodiazepines and Z-drugs at national level.