gms | German Medical Science

Background: Both benzodiazepines and Z-substances (zopiclone, zolpidem), which are prescribed as hypnotics, sedatives or tranquilizers, exhibit a potential to cause addiction, dependence and abuse [1], [2]. The current state of research does not allow for a definite statement about the extend to which the risk is or may be lower in the Z-substances [3], which is why both agents should be used only briefly for diseases such as insomnia [4].

The prescription of benzodiazepines at the expense of statutory health insurances has declined significantly since the introduction of the Z-substances in the 1990s. The number of prescribed packages of benzodiazepines in 1993 amounted to 12.7 million [5], in 2012 merely to 2 million [6]. The Z-substances, however, have experienced an increase of 2.2 million from 1993 to 2012 with 7.9 million packages [5], [6]. Less hypnotics are prescribed overall [6]. Nevertheless, it has been assumed for many years that there are an estimated 1.3 million drug addicts, of which a large part is addicted to these aforementioned drugs [7]. Doctors and pharmacists are endeavoured to reduce the number of drug addicts [8], [9].

The decline in the number of prescriptions in its entirety (benzodiazepines plus Z-substances) does not correlate with the sales statistics of the wholesale trade, which supplies pharmacies, as investigations of the years 1993 to 2012 show [5], [10], [6]. The proportion of packages sold to benzodiazepines without presentation of a medical prescription' in 1993 amounted to 13.4%, in 2004 to 55.4% [5] and in 2012 to 55.3% [10]. Concerning the Z-substances, an increase of 5.3% (1993) to 48.2% (2004) and 49.5% (2011) has been observed [6, 7]. It is believed that this is due to private prescriptions [5], [10], [6].

The aim of this study is to find empirically the percentage of benzodiazepine and Z-substance prescriptions as medical prescription and private prescription for patients with standard statutory health insurance in North Rhine-Westphalia on the basis of submitted prescriptions in pharmacies.

Materials and Methods: Within the remit of social pharmacy public health services in North Rhine-Westphalia, pharmacists, in cooperation with participating pharmacies, observed the prescriptions of hypnotics, sedatives and tranquilizers of the class of benzodiazepines and Z-substances.

The survey was conducted in two steps, each of which was adapted to the two parts of the country. In 2014 those pharmacies in Westfalen-Lippe which had been certified AMTS (drug therapy security) pharmacies through the Chamber of Pharmacists in Westfalen-Lippe, have been invoted to participate in writing. In 2015, health authority pharmacists wrote to selected pharmacies in the district of Nordrhein and asked for voluntary cooperation.

In a total of 40 pharmacies in Westfalen-Lippe and 105 pharmacies in Nordrhein, the pharmaceutical staff documented (from June to September in 2014 and from April to July or from May to August in 2015) each prescription of benzodiazepines and Z-substances for three months. A classification of patients by gender was carried out, by age group (under 45 years, from 46 to 65 years and over 65 years) and by insurance status (whether statutory or private). Furthermore, it was captured if it was a benzodiazepine or Z-substance prescription and whether the regulation was ensued as a standard medical or private prescription.

Results: After preliminary evaluation, every fourth person covered by the statutory health insurance, received a private prescription of hypnotics, sedatives and tranquilizers of the class of benzodiazepines and the Z-substances. The share of private prescription for people covered by the statutory health insurance varied very strongly from one pharmacy to another. Based on the available data it can also be noted that the shares of the private prescription of benzodiazepines and Z-substances in the districts of Nordrhein and Westfalen-Lippe could vary very much.

Conclusion: The current study is a non-representative study of the public health service in North Rhine-Westphalia in cooperation with selected pharmacies. After preliminary evaluation based on the available data, it cannot be confirmed that about half of all prescriptions of benzodiazepines and Z-substances for persons covered by the statutory health insurance took place on private prescription, which was shown in previous studies focused on Germany. It appears, however, that private prescriptions of SHI-patients were presented in a large number of participating pharmacies.

The investigation confirmed that physicians prescribe benzodiazepines and Z-substances for SHI-insured to an appreciable extent on private prescription. As benzodiazepines and Z-drugs can cause dependence, there is still a need for action. More pharmacies based studies at local or regional level could help to clarify where these drugs are mainly prescribed on private prescription. Based on this it could be discussed what are the reasons and what to do to take action against drug addiction.