Characteristics of the use of benzodiazepines by women seeking treatment in primary care

Abstracts

INTRODUCTION: Benzodiazepines are psychotropic drugs whose prescription is indicated for acute crises of anxiety, insomnia and convulsions. Its use is most of the times inadequate. This study aimed at identifying the profile of the female benzodiazepine user at primary care and the characteristics of use. METHODS: All patients over 18 years old were questioned about their benzodiazepine use at a primary care unit from Sorocaba, Brazil, in the year of 2008. RESULTS: Benzodiazepines were used by 13.14%, mainly by older women (50-69 years old), in a stable relationship and illiterate. The use was mainly due to insomnia (48.14%), of longer half-life drugs, chronic (over 6 months, 89.14%), with first prescription by the general practitioner (47.82%) and high rates of interruption (91.3%) failures (69.05%). DISCUSSION: The use is 3.3 times higher than described in the literature for women of similar profiles, with generally inadequate prescriptions, independently of the first prescriber (specialist or not). CONCLUSION: Use is chronic, mainly by older women, with lower educational level and who are in a stable relationship, for correct reasons, but for inadequate time of treatment.

Drugs prescription; benzodiazepines; primary care; women

INTRODUÇÃO: Benzodiazepínicos são medicamentos psicotrópicos de prescrição restrita utilizados para crises agudas de ansiedade, insônia e convulsões. Sua utilização é muitas vezes inadequada. O objetivo deste trabalho é identificar o perfil da usuária de benzodiazepínicos na atenção primária e as características de sua utilização. MÉTODO: Foram entrevistadas todas as pacientes maiores de 18 anos em espera para atendimento em uma unidade básica de saúde de Sorocaba (SP) em 2008. RESULTADOS: Foi encontrada utilização de benzodiazepínicos por 13,14% das frequentadoras da unidade básica de saúde, sendo maior em mulheres de 50 a 69 anos, em relacionamento estável e analfabetas. O uso encontrado foi principalmente por insônia (48,14%), de medicamentos de longa meia-vida, crônico (mais de 6 meses, 89,14%), com prescrição inicial principalmente pelo clínico geral (47,82%), com alta taxa de tentativas de interrupção (91,3%) infrutíferas (69,05%). DISCUSSÃO: A utilização é 3,3 vezes maior do que a descrita na literatura para mulheres de perfil semelhante, com prescrições em geral inadequadas, independentemente do prescritor inicial (especialista ou não). CONCLUSÃO: O uso é crônico em mulheres mais idosas, de menor escolaridade, de relacionamento estável, por motivos corretos, porém de tempo de tratamento inadequado.

Prescrição de medicamentos; benzodiazepínicos; atenção primária; mulheres

ORIGINAL ARTICLE

Characteristics of the use of benzodiazepines by women seeking treatment in primary care

David Gonçalves Nordon^I; Karin Akamine^II; Neil Ferreira Novo^III; Carlos von Krakauer Hübner^IV

^IAcadêmico, Medicina, Pontifícia Universidade Católica de São Paulo (PUC-SP), São Paulo, SP

^IIAcadêmica, Medicina, PUC-SP

^IIIDoutor, Professor, Bioestatística, PUC-SP

^IVDoutor, Professor, Psiquiatria, PUC-SP

Trabalho realizado na Pontifícia Universidade Católica de São Paulo (PUC-SP), São Paulo, SP

Endereço para correspondência

ABSTRACT

Introduction: Benzodiazepines are psychotropic drugs whose prescription is indicated for acute crisis of anxiety, insomnia and convulsions. Its use is frequently inadequate. This study aimed at identifying the profile of the female benzodiazepine user at primary care and the characteristics of use.

Methods: All patients over 18 years old were questioned about their benzodiazepine use at a primary care unit from Sorocaba, Brazil, in the year of 2008.

Results: Benzodiazepines were used by 13.14%, mainly by older women (50-69 years old), in a stable relationship and illiterate. The use was mainly due to insomnia (48.14%), of longer half-life drugs, chronic (over 6 months, 89.14%), with first prescription by the general practitioner (47.82%) and high rates of interruption (91.3%) failures (69.05%).

Discussion: The use is 3.3 times higher than described in the literature for women of similar profiles, with generally inadequate prescriptions, independently of the first prescriber (specialist or not).

Conclusion: Use is chronic, mainly by older women, with lower educational level and who are in a stable relationship, for correct reasons, but for inadequate time of treatment.

Keywords: Drugs prescription, benzodiazepines, primary care, women.

INTRODUCTION

Available since 1960 and with a rigorous control for its prescription due to tis addiction potential, through the blue form and prescription retrieval, benzodiazepines (BZDs) are one of the most prescribed classes of psychotropic drug nowadays.¹

In Brazil, they are the third more prescribed class of drugs,² used by around 4% of the population.^3-5 Nowadays, BZDs are indicated only for acute and subacute treatment of anxiety, insomnia, and seizure crises, although in the past they have been used as first line treatment for various disorders, mainly psychiatric.⁶

Since their anxyolytic effect decreases with time (generally 3 to 4 months), the BZDs are not indicated for long term treatment and they lose their place for Z drugs (GABA receptors agonists, as zolpidem and zaleplam), which, in spite of being more expensive, have a similar efficacy and less side effects.⁷ Other concerning factors related to BZDs that currently lead us to restraint their prescription is the capacity of generating tolerance and dependence, which may be perpetuated by several factors: erroneous and continuous prescription by the physician; increase of dosage by the patient; psychological need for the drug (something very usually observed in outpatient clinics environment). It is believed that the currently the greatest factor for perpetuating the habit is this addiction, having in mind, as exposed above, that chemical and physical dependence on BZDs are not so strong as that of other drugs of abuse.^2,8-13

Tolerance, on the other hand, is more difficult to be found, especially in older patients, who develop it even without increasing the doses, due to alterations typical of old age.¹⁴

SCN and TCAP occur more often in obese patients, but also in those with normal weight, possibly contributing to the development and maintenance of obesity. They have been associated with delay in circadian rhythm, impaired satiation, depressed mood, stress, low self-esteem and psychiatric comorbidities.^13,14

BZD users are mostly women (two to three times more common than men), and their numbers increase with age. In Brazil, it is used mainly by divorced women or widows, with low income, between 60 and 69 years old.^2,4,11 Their use is thrice more probable in patients carrying psychiatric disorders.¹⁵

The prescription of these drugs in general is also improper, especially in the primary level of care, according to various articles.^16-23 The main reasons for this are the lack of time, underestimation of the number of users, severity of use, side effects and even the non observation of the guidelines.

Brazil suffers from a lack of data about the use of BZDs, especially for the population of users of basic health units (BHUs), the steeple of primary care. This way, it is interesting for public health to analyze the users, their socioeconomical and usage profile, in addition to the prescription adequacy, in this scenery frequented mainly by women.

METHODS

Throughout the year of 2008 (January to December), Medicine students from the Pontifícia Universidade Católica de São Paulo interviewed, on Friday mornings, interviewed the patients who were waiting for treatment in the BHU of Vila Barão, Sorocaba, SP, older than 18 and who agreed in participating and signing the informed consent form. Inclusion criteria were: agreeing in participating and signing the informed consent form; being of the female sex; over 18 years old; be enrolled in the BHU, by means of a registration number and a medical file.

The BHU of Vila Barão is a small unit in a suburban neighborhood of Sorocaba, attending around 14,000 patients, including a big portion of non-lotted land inhabitants. It is composed mainly of a low income and low educational level population. The BHU includes the services of general practice, pediatrics and gynecology, with no other facilities as orthodontia, psychology or psychiatry.

The interviewees answered a questionnaire elaborated by the researches for this end, filled by the researchers with name, marital status, educational level, income per capita in minimum wages and if they used BZDs or not. Then the users answered a second series of questions about the characteristics of usage: 1) benzodiazepine used; 2) reason for using (self-reported); 3) time of use; 4) first prescriber of the drug; 5)current prescriber; 6) previous attempts of interrupting the usage; 7) success or failure in this interruption; and 8) reason for not succeeding in the interruption.

The interviewees were, then, grouped according to the characteristics: 1) age: 18-29 years; 30-39 years; 40-49 years; 50-59 years; 60-69 years; 70 years or more; 2) marital status: married, single, widow or cohabiting; 3) educational level: illiterate, up to 8ª grade of primary education, and secondary/higher education; and 4) family income per capita: up to 3 minimum wages and four or more minimum wages.

For results analysis, the chi-squared test or Fisher exact test²⁴ were used, with the objective of comparing age groups, marital status, educational level, and other characteristics related to the use or not of BZDs. In all the tests the level of significance was set in 0.05 or 5%.

This work was approved by the Research Ethics Committee of the Medical and Biological Sciences Center of the Pontifícia Universidade Católica de São Paulo (PUC-SP), São Paulo (SP), in 06/12/07.

RESULTS

Throughout the year of 2008, 350 women were interviewed in the BHU of Vila Barão, Sorocaba (3% of the total population, including men and women, reached by the BHU, approximately). Out of these, 46 (13.14%) were BZDs users, and 304 (86.86%) were not, significantly disagreeing with international data, which show the use by approximately 4% of general population.^3-5

The answers to the items in the questionnaire are quantified in Table 1 for general frequenters, and in Tables 2 and 3 exclusively for users.

As observed in Table 1, the age group of women between 18 and 39 years old (200 people, or 57% of the sample) present a significantly lower consume of BZDs than the 50-59-year-old group (p < 0.001).

The results showing the frequenters' marital status only suggest that women in a stable relationship (married or cohabiting; 67.42%) consume more than single women or widows, since statistic analysis was not significant.

The educational level of the frequenters and users is showed below; illiterate women consume significantly more BZDs than women with higher educational levels (p < 0.05).

Table 1 displays also estimated per capita family income of the frequenters, self-reported; the data, however, were not statistically significant, with only a mild suggestion that women with lower income use more BZDs.

Table 2 shows all the results of our survey, with the number of answers and percentage of corresponding population of users.

The greater reason for use (which could be more than one) was insomnia (48.14%), followed by anxiety (39.5%) and seizures/epilepsy (8.64%). Two women informed as reason treatment for depression, and one informed bereavement (but not anxiety).

In relation to medications being used, the most referred was diazepam (76.08%), followed by clonazepam (8.68%) and combined therapy including both (6.25%), both possible to be acquired at the BHU. Four women reported using other BZDs, not acquirable through the Sorocaba public health system.

Time of use was prolonged (more than 6 months) in 89.14% of the studied population.

The main prescriber is the general practitioner (47.82% of the users), followed by psychiatrists (36.95%). None of the users had their first prescription via a pharmaceutist; however, one user still reported having received her initial prescription by the cardiologist, another one by the endocrinologist, and three by the neurologist (6.52%).

For the majority (65.21%), the main current prescriber is the general practitioner of the health center they frequent, who frequently uses the same prescription for a long time. Prescription by psychiatrists, however, suffers a small and non significant reduction in relation to initial prescription, while that of other specialists counts on only one cardiologist, instead of the initial general practitioner.

The great majority of women (91.3%) tried to interrupt the usage. Only 30.95% of the sample was successful; the main reason, for most cases, was the persistence of symptoms reported before the use. Other complaints were reported, among them the death of a relative (a user) and the non permission, by a doctor, of interrupting the treatment (a user). This user justified the use of the medication on anxiety, insomnia and seizures, and used it for more than 3 months, by initial and current prescription by a psychiatrist.

Table 3 shows the answers of the users according th their initial prescriber.

The main reason for isolated prescription by general practitioners was insomnia (40.9% of the users); when combined, it generally came with anxiety (40.9% of the users). The general practitioner prescribed BZDs for only two cases of seizure, one accompanied by insomnia, the other by anxiety. On the other hand, for psychiatrists, insomnia was usually not an isolated factor (only 5.88% of users), but was accompanied by other complaints, as anxiety and seizure (82.35% of users). It is remarkable how six or those who reported seizures as the initial cause for prescription were treated by the psychiatrist, two by the general practitioner, and none by the neurologist, the specialist indicated for such.

Depression was another reason reported, treated initially by the psychiatrist in two cases, still receiving his prescription today, in a treatment of more than 3 years and, in the other case, by a general practitioner (who was not the specialist indicated for such).

DISCUSSION

Data obtained through this study reflect characteristics of this neighborhood and also of primary care itself, while the studies used for comparison present data obtained through averages by multicenter studies, which both homogenizes the sample and removes it from reality (the authors did not find equivalents in Brazil for comparing data). In face of that, the difference of results related to the use, much more elevated in th BHU (3.3 times more than the one found in international literature) is explained. In relation to national literature, a 1988 study of the population of Rio de Janeiro (RJ)⁴ showed a usage of psychotropics, in the last 30 days, by 6.7% of the women, with 85.23% of these drugs being BZDs, representing, yet, less than half the value found in this study. There is, nonetheless, a similar study to this one, of primary care in Spain,¹⁶ which found in 1997 a relative risk of 1.57 for BZD use by women, in comparison to men, totalizing in 11%, a similar number to the one arrived at in this study.

Besides that, it was hypothesized that the consumption is increased in this studied population due to various factors characteristic of the place studied: environment and social interactions (Vila Barão is a low income region, with higher violence rates when compared with other neighborhoods in Sorocaba) and higher misinformation of physicians working in health centers, maybe due to a lower encouragement to updating, among other factors, besides others already mentioned that alter the prescription to a primary level.^16-23

The age group with higher usage rates is in accordance with what is described in the literature, although the tendency observed is even higher in older women, 20-29 years old,^4,16,20-22 while this study showed a broader age group (50-69 years old). It was discovered that women in stable relationships present a greater tendency to use, which is in accordance with the Spanish study of primary attention¹⁶ and with an Italian study of a mental health specialized service,²⁵ but is in disagreement with data of the Rio de Janeiro study,⁴ which presented a greater use by widows.

A statistically significant association between illiteracy and higher use of BZDs was found, but not between lower income and higher use, which can be explained by the general low income of the population studied, with the higher income sample not being significant. The study in Rio de Janeiro⁴ has also found an association between lower income and educational level and higher use; the Spanish study,¹⁶ is equally in accordance with these two in relation to the time of study, but the Italian study²⁵ found a less significant difference, once it divided the educational level in more or less than 8 years of study, contrarily to other studies, which divided it in more categories, as this one.

This demonstrates a dangerous correlation, in which less informed people and with lower income frequently end up using drugs for solving psychosocial problems that could be solved in another way.

The main reasons of usage reported by the patients were the complaints for which the prolonged use of BZDs is not indicated, but only the acute use.⁶ As demonstrated before, for virtually all the users (89.14%), usage was chronic and, therefore, inadequate, probably due to misinformation or to the fact that the BHU doctors, in creating an affectionate relationship with their patients, do not feel comfortable to deny them the medications usually demanded, as described in the literature.^15,17,20 Such a profound investigation, though, was not the focus of this research.

It is important to highlight that, although BZDs may be used in a controlled manner for diminishing side effects of antidepressive drugs in the beginning of the treatment for panic syndrome, they are in no way directly indicated for depressive disorder; in relation to bereavement, for being a theoretically autolimited alteration, the BZDs could be used (in spite of no existing clearly expressed indication for such) for the acute control of anxious symptoms or insomnia, but they should be withdrawn as soon as these symptoms were over, which is not observable in the chronic user that cited bereavement as initial reason of prescription by the general practitioner.

In relation to the drug of choice, practically only the indispensable ones in the Sorocaba UBH were prescribed, which are, unfortunately, longer half-life BZDs and, so, more prone to side effects, so that this prescription mistake cannot be attributed to the doctor, but to the health care system. It is important to highlight that the longer half-life BZDs, especially for old people, may be dangerous, due to side effects of their metabolites, which take longer to leave the body.

The high incidence of attempts to interrupt BZDs use may be a reflex of the reason for using them itself: the complaint about anxiety is the second more prevalent (39.5%), which is relatively controllable according to the psychosocial motivations. Insomnia may also be an intermittent complaint (and controllable according to anxiety), which would lead to a higher incidence of interruption of chronic use. Besides that, it is interesting to perceive that 100% of the convulsive patients tried to interrupt the treatment, and only one succeeded, partially. Combined therapy user, she stopped using only one of the drugs (clonazepam), showing that the indication of the drug not only is inadequate, but also misguided. Similarly, the success rate in interruption was low, which may be due to a probable dependence of the users on the drug, frequently psychological, as described in literature.

Notwithstanding, the interruption attempts are a good sign, because they indicate that the population is aware of the consequences the continuous use of BZDs may bring about, which should be used by responsible physicians to adequate the treatment.

It would be ideal if the initial prescriber was the psychiatrist, specialist in this kind of medication; however, as this is a primary care scenery, it is natural that almost half the prescriptions (47.82%) are done by the general practitioner. The study in Rio de Janeiro⁴ discovered a prescription by non-specialists (neurologists/psychiatrists) of 68.5%. In the same way, the continuity of the treatment in primary care or the transference from a secondary/tertiary service for a primary service is natural.

Following this evaluation, the chronic use, established in this study as over 6 months, was observed with a high prevalence for all the prescribers (94.11% for psychiatrists and 81.81% for general practitioners), being apparently more prevalent among psychiatrists, but not statistically significant (p = 0.2617). Unfortunately, for the user who obtains the medications without a prescription, its use is also chronic. As already mentioned, the BZDs should not be used for over 3 or 4 months, due to the loss of their anxyolytic function and its effect against insomnia and to the potential side effects that their use may bring in the long haul (cognitive loss, productivity impairment, higher probability of car accidents).

Almost half (41.17%) the patients attended initially by the psychiatrist were directed to th general practitioner, reflecting the counter-reference of a specialized service to a primary service. A user passed from the psychiatrist to the cardiologist; among those who received the first prescription from the general practitioner, the tendency was to remain with them, except for three users (13.63%) who were referred to a specialized follow up. Therefore, a health care service frequently involving the plain maintenance of the prescription and the indication by other professional is observed, without a specialized follow up. And even among those who remained with the specialized treatment there was no difference in relation to the time of use, which is, the use of longer half-life drugs is chronic and, so, is subject to a higher tolerance, dependence, and side effects, regardless of the specialty of the physician prescribing.

However, this study has some limitations: it is limited to the female patients of a primary service in a low income neighborhood, so the results cannot be generalized for other sceneries; the reason for use was self-reported, liable, thus, to alterations according to the user's understanding, so that the evaluation of the suitability of the indication was not totally reliable (which was not the primary objective of the research) – other data about the prescription, however, are assessable with a satisfactory reliability; finally, there are no similar studies in our reality of primary care for us to compare the data, therefore resulting in the necessity of comparison with rare international sources.

CONCLUSION

In this work, a pattern of BZDs use by women in a BHU was observed, reflecting the characteristics of a low income and low educational level population, in which a more than three times higher number of consumers than the one seen in international literature is reported, with the main consumers belonging to the 50-69-year-old age group, in a stable relationship and illiterate. The use of longer half-life BZDs is chronic and, therefore, has greater side effects, due to the wrong reasons, with prescriptions by physicians who are not primarily indicated for the function, and a high failure rate in attempting to interrupt the use. The prescribers are generally general practitioners, but even the specialists have shown to be inadequate prescribers, using longer half-life BZDs for a prolonged time, not following the conduct norms⁶ and for complaints that frequently could be controlled in other manners, such as a greater psychosocial action.

The authors believe that this work can contribute a little to the knowledge of the characteristics of the female population treated by the primary health service in poor neighborhoods, not exclusively in Sorocaba, but in the whole region. The need for more studies about this topic, having in mind the hazardous consequences of the prolonged use of BZDs, is mandatory, as well as the orientation and periodical recycling of health professionals of all the specialties about the use, abuse, and side effects of these drugs.

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Publication Dates

• Publication in this collection
  24 May 2010
• Date of issue
  Dec 2009

History

• Accepted
  19 Nov 2009
• Received
  27 July 2009