ORIGINAL PAPER

Factors associated with high prescribing ofbenzodiazepines and minor opiatesA sur�ey among general practitioners in NorwayTrine Bjørner1 and Even Lærum2

1Department of General Practice, University of Oslo, 2The Norwegian Back Pain Network, Ulleval UniversityHospital, Oslo, Norway.

Conclusion – Emotional and relational aspects play an importantScand J Prim Health Care 2003;21:115–120. ISSN 0281-3432part in decisions on prescribing benzodiazepine and minor opiates.

Objecti�e – To determine the factors associated with high-volume Our findings indicate that there is potential for improvement inprescribing practice; for instance, by investigating how and to whatprescribing of benzodiazepines and minor opiates – backgroundextent prescribing decisions are influenced by patients and how thecharacteristics, personal prescribing habits and general attitudes todifficulties experienced influence the decision process. Better practiceprescribing.

Design – A questionnaire survey. Descriptive statistics, bivariate routines could be considered such as not prescribing these drugswithout consultation.analysis and multiple logistic regression.

Setting – General practitioners in Norway.Key words: benzodiazepines, minor opiates, general practice, pre-Subjects – Every third general practitioner from the list of members

of the Norwegian Medical Association. scribing, patient influence, doctor’s gender.Main outcome measures – Odds ratios for being a high prescriber.Results – The main predictors of high-volume prescribing were: pa- Trine Bjørner, Department of General Practice, Uni�ersity of Oslo,

P.O. Box 1130 Blindern, NO-0317 Oslo, Norway. E-mail:tients allowed to influence prescribing decisions, benzodiazepines andtrine.bjorner@samfunnsmed.uio.nominor opiates prescribed without consultation, prescribing perceived

as difficult and the doctor being male.

The use of benzodiazepines with risk of dependency,over-dosage and abuse has given rise to much concern(1,2). Significant variation in doctors’ prescribing vol-umes and prescribing patterns has been shown (3,4),but few attempts have been made to understand thesedifferences. Social and non-medical factors have beenreported as influencing psychotropic drug prescribing(5,6).

According to drug legislation in Norway, prescrip-tions for benzodiazepines and minor opiates, i.e. anal-gesics with codeine, are registered in pharmacies for thepurpose of supervision by the health authorities. Alldrugs in this group are potentially addictive, and giverise to similar concerns, in terms of patients’ misuse,abuse and also how doctors prescribe according togiven guidelines. Benzodiazepines constitute approxi-mately 80% of the total prescribed quantity of thesedrugs (7). Of the total amount of benzodiazepines andminor opiates that are prescribed, 80% is prescribed inprimary health care (8). Accordingly, this study wasperformed among general practitioners (GPs).

In 1994, we performed a qualitative study of GPs’benzodiazepine and minor opiate prescribing (9,10).This study explored why some doctors are high pre-scribers and how they legitimise their prescribing bymaking use of various working strategies, mainly by

ascribing responsibility to patient autonomy, to pa-tient’s age and concomitant diseases and to the pa-tient’s previous doctor, who first started themedication, and also by making silent agreements forcontinuous prescribing (9). We also studied how GPsby the use of simplifying models transform theirpatients’ stories into a few categories for interpretationthat can serve as strong or clear-cut arguments fordecisive action (10).

The aim of the present study was to determine whichfactors, in terms of background characteristics, per-sonal prescribing habits and general attitudes to pre-scribing of benzodiazepines and minor opiates areassociated with high prescribing volumes of thesedrugs.

Prescribed volumes of benzodiazepine and minoropiates show significant variations among doctors.

� Prescribing increases when doctors allow pa-tients to influence prescribing decisions.

� Prescribing increases when there is no face-to-face doctor–patient contact.

� Male doctors are more prone to prescribe benzo-diazepines and minor opiates than female doc-tors are.

DOI 10.1080/02813430310001734 Scand J Prim Health Care 2003; 21

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T. Bjørner, E. Lærum116

SUBJECTS AND METHODSSampleA random sample of 1385 GPs was selected bydrawing every third GP from the list of members ofthe Norwegian Medical Association, where approxi-mately 97% of all Norwegian physicians are members(11).

QuestionnaireIn March 1998, the interviewees received a postalquestionnaire. In order to ensure confidentiality, theresponders were asked to return the questionnaire andthe enclosed registration card separately, giving theopportunity to send a reminder to non-responders.

The questionnaire was based on the former qualita-tive studies (9,10), and comprised two main sections:one for general attitudes to prescribing benzodi-azepines and minor opiates and another section for therespondents’ prescribing habits of these drugs. Therespondents were also asked for an estimation of theirown prescribing volumes by giving an approximationof how many prescriptions they had issued on theirlast practice day. At last there was a section forbackground characteristics, i.e. gender, age, medicalspeciality, years of experience in general practice andwhether the GP worked in a group practice or asingle-handed practice.

There were 36 items concerning prescribing atti-tudes and practice. These items were extracted fromthe main findings in the qualitative studies by theauthors of these studies, and finally agreed on after apilot study among 24 GPs was performed. The itemscovered emotional, cognitive, relational and situa-tional aspects of doctors’ prescribing decisions byasking about patient demands and patient autonomy,working strategies, and arguments used for makingprescribing decisions.

Five items were opposite wordings of other ques-tions for validation purposes.

All items were presented as statements, and theanswers were recorded on a 5-point Likert scale withfully agree and fully disagree as endpoints and indiffer-ent in the middle.

Statistical methods and data analysesStatistical analyses were performed using SPSS forWindows. Descriptive statistics, bivariate analysis andmultiple logistic regression analysis were applied (12).

After correlation tests (Spearman’s) had been per-formed, the former mentioned validation questionswere omitted before the logistic regression analysiswas performed. Nine items were omitted before thelogistic regression analysis because of reports of possi-ble misinterpretations (notes made by the respondentsin the questionnaires).

The background variables and the remaining 21 ofthe original 36 items were chosen as the independentvariables in a multiple logistic regression analysis.

The GPs’ approximation of how many prescriptionsthey had issued on their last practice day was chosenas outcome variable. For the logistic regression thisvariable was dichotomised into zero to five prescrip-tions issued on the last practice day, categorised as lowprescribing, and six or more prescriptions issued onthe last practice day, categorised as high prescribing.This categorisation was based on what has beenconsidered as high prescribing volumes among GPs(4).

Bivariate analyses of background characteristicsand item scores with the outcome variable were per-formed (Independent sample t-test and chi squaredtest).

Using a multiple logistic regression with backwardsstepwise selection procedure we analysed how theself-estimation of prescribing was associated with the21 items and with background characteristics. Statisti-cal significance was defined as p-value �0.05 and 95%confidence intervals were given.

Instead of using the original Likert scale in theanalysis, the items were coded with numerical valuesaccording to the following list: Those who fully dis-agreed were assigned the value 0, those who partlydisagreed 0.25, those who were indifferent 0.5, thosewho partly agreed 0.75 and those who fully agreed 1.Thus, the values can be seen as fractions of fullagreement. Consequently, the estimated OR (oddsratio) for each item represents the odds for being ahigh prescriber for one who fully agrees, compared toone who fully disagrees.

The Hosmer Lemeshow goodness-of-fit test and aplot of Cook’s distance versus predicted values, withpoint size indicating influence values (13), were per-formed. As a further check of the model a linearlogistic regression of significant items with the approx-imation of prescriptions issued was performed.

RESULTSSample characteristicsBackground characteristics are listed in Table I. Of the1385 GPs, 1018 (74%) responded. Approximately 1/3were female doctors. The respondents’ mean age was45 years, and nearly 60% of them were specialists ingeneral practice. Eighty-six percent reported to issuebelow six prescriptions daily. Fourteen percent hadissued 6 to 11 prescriptions daily, and 0.7% had issuedmore than 11 prescriptions last practice day.

Background characteristicsDoctor’s gender, age and years of experience in gen-

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High prescribing of benzodiazepines and minor opiates 117

Table I. Background characteristics and self-rated prescribingvolumes of benzodiazepines and minor opiates of 1018 GPs.

Number/meanCharacteristics %

Gender285Female 29716Male 71

Age 45Years in practice 15Specialist

598 59Yes410No 41

Practice location386 39Rural391Small town 39

City 216 22Practice type

748Group 77Single-handed 224 23

Approximate number of prescriptions issued during the lastpractice day

150 150693 711–51296–10 13

7 0.7�10

Predictors for being a high prescriberThe findings of the multivariate analysis are given inTable III. The most important predictors for being ahigh volume prescriber were: to allow patients toinfluence prescribing decisions, to prescribe benzodi-azepines without consultation, to perceive prescribingas difficult and conflicting with given guidelines, andto be a male doctor, all showing OR�2. High pre-scribers also thought that benzodiazepines should beprescribed only for special indications or well-definedproblems.

Low prescribers tended to believe that chronicbenzodiazepine use is due to abstinence and addic-tion. They believed that these drugs were often thebest they could offer their patients, and they wereaware that these drugs might be sold illegally.

Items that did not show statistical significance werepower struggle between the doctor and the patient inthe consultation, that patients might not get thenumber of prescriptions really needed, patient’s re-sponsibility for his or her own drug use and inherit-ing patients with chronic drug use from otherdoctors. Items of low statistical significance not indi-cated in Table III were whether doctors had personalrules for prescribing, whether doctors and patientshad silent agreements for continuous prescribing andthe belief that patients would consult another doctorif they did not obtain the prescription they asked for.

Background variables without statistical signifi-cance were: being a specialist in general practice andyears in practice.

A Hosmer Lemeshow goodness-of-fit test did notreject the model fit (p=0.53). A Cook’s plot fordetection of influential observations did not detectany individuals poorly fit or with undue influence onthe estimates.

The linear logistic regression showed that the mainresults were robust against different choices of regres-sion methods.

DISCUSSIONThe main findings of this study are that emotionaland relational aspects are significantly associated withhigh prescribing of benzodiazepines and minor opi-ates. We also found that prescribing without directdoctor–patient contact was a predictor of high pre-scribing, and that male doctors prescribe more thanfemale doctors do.

We found that doctors with high-prescribing vol-umes more often than doctors with low-prescribingvolumes reported that patients’ demands influenceprescribing decisions. Earlier studies have shown thathow doctors perceive their patients’ expectations forgetting a prescription is a strong determinant for

Table II. Bivariate associations between background variablesand prescribing volumes (independent sample t-test and chi-squared test).

Self-rated prescribing volume

High N (%)Low N (%) p-value

GenderFemale 254 (94) 17 (6)

574 (82) 118 (17)Male 0.0001Age

Mean 44 45 0.02Years in practice

Mean 13 15 0.01Specialist

Yes 495 (85) 85 (15)No 338 (87) 51 (13) 0.28

Practice typeSingle-handed 28 (13)189 (87)Group 620 (86) 102 (14) 0.37

Practice locationRural 321 (87) 48 (13)Suburban 314 (84) 61 (16)City 186 (87) 0.3427 (13)

eral practice showed statistically significant associa-tions with prescribing volumes (as indicated) in TableII. Age and years of experience in practice werehighly correlated: correlation coefficient=0.86.Hence, only years in practice was chosen for thelogistic regression.

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T. Bjørner, E. Lærum118

Table III. Predictors of high prescribing versus low prescribing according to background variables and questionnaire items(multiple logistic regression).

Odds ratio 95% CI P-value

1.0Gender FemaleMale 2.7 1.4–5.3 0.0031

Item no. 3: Perceives prescribing as difficult and what seems best for the patient DisagreeAgree 3.4 1.1–10.6 0.0398as contrary to guidelines.DisagreeItem no. 6: The drug demand of chronic users is due to abstinence andAgree 0.3 0.1–0.8 0.0219addiction.DisagreeItem no. 9: For many patients, benzodiazepines are the best we can offer.

0.4 0.1–1.0Agree 0.0392Item no. 14: Benzodiazepines should only be prescribed for special patients with Disagree

Agree 3.4 1.5–7.8 0.036very special problems.DisagreeItem no. 22: I often prescribe benzodiazepines to chronic users by telephone.Agree 3.5 1.5–8.3 0.0043DisagreeItem no. 32: When the patient first asks for it, he or she always ends up with aAgree 3.8prescription. 1.2–11.6 0.0204DisagreeItem no. 34: I am aware that the medicines I prescribe should not go to resale.Agree 0.5 0.2–1.0 0.0423DisagreeItem no. 19: In consultations where benzodiazepine prescribing is discussed,Agree 0.4 0.2–1.1 0.0834there is a power struggle going on between the doctor and the patient.DisagreeItem no. 5: I think that I prescribe fewer benzodiazepines than patients reallyAgree 0.4 0.1–1.3 0.1446need.

Item no. 28: In the end it is the patient himself or herself who has responsibility DisagreeAgree 1.8 0.8–3.8 0.1416for his or her own drug use.DisagreeItem no. 18: Most chronic users are inherited from other doctors.

1.9 0.8–4.7 0.1815Agree

prescribing (14). There is a growing trend for patientpartnership in decision-making, and there is evidencethat this gives positive effects in care (15). However,our finding might reflect that doctors put too muchemphasis on patients’ wishes, and also that comply-ing with patients might be interpreted as a resignationamong high-prescribing GPs, maybe to avoid difficultand time-consuming discussions, in the name of pa-tient participation.

We also found that a willingness to prescribe tochronic users without a consultation is more commonamong high prescribers than among low prescribers.This might indicate that few efforts are made tofollow up the use of these drugs, and that someprescribing may be done with sparse medical evalua-tion. This finding is in line with other studies showingthat between 50% and 80% of benzodiazepine pre-scriptions are issued without direct doctor–patientcontact and that many are repeat prescriptions(16,17). Furthermore, this suggests that it is easier forwell-known patients with well-known problems,rather than for less well-known patients, to obtain aprescription for benzodiazepines or minor opiates.This is in line with other studies (17,18) and mightindicate that changing or withdrawing drug use canbe particularly difficult when there is a close doctor–patient relationship. Continuity of care, which ismost often regarded as a benefit, may represent adifficulty in these prescribing decisions (19).

Another important finding in this study is thatdoctors with high-prescribing volumes reported thatprescribing often brings them into difficult situations,and that what they considered necessary medicationfor their patients might be contrary to given guideli-nes. This last finding might indicate that prescribingof the actual drugs is perceived as a challenge tomainstream medicine, and even that doctors feelforced to prescribe contrary to guidelines. This dis-crepancy between actual prescribing and what mightseem more appropriate could indicate that prescrib-ing brings doctors into uncomfortable prescribingsituations as earlier described by Bradley (20).

These difficult situations associated with prescrib-ing can be understood both as an influencing factorand as a consequence: That patients’ demands forprescriptions cause emotionally difficult situationsthat lead to prescribing, or that the perceiveddifficulties are caused by the prescribing itself.

All these findings suggest that non-medical factorsare important in prescribing decisions. The influenceof non-medical factors might reflect a lack of aware-ness of non-drug treatment for minor psychiatricillness and maybe an under-estimation of well-knownside effects of benzodiazepines. It is also possible thatinsufficient efforts have been made to implementguidelines (21).

We found that male doctors prescribe significantlymore benzodiazepines and minor opiates than female

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High prescribing of benzodiazepines and minor opiates 119

doctors do. Other studies have not shown such genderdifferences (22). It is well known that female patientsuse more psychotropic drugs than male patients do(23). Combined with the trend that female patientstend to prefer female doctors, our finding might seemsurprising. The doctor gender difference in benzodi-azepine and minor opiate prescribing might indicatethat female doctors treat patients differently than maledoctors do. This is in accordance with earlier findingsthat female doctors are more concerned about psycho-social aspects and have longer visits than their malecolleagues (24), or that female doctors have been moreinfluenced by campaigns to reduce prescribing.

No statistical differences in prescribing volumeswere found between specialists and non-specialists infamily medicine. This may indicate that drug prescrib-ing is paid little attention in specialist education.

Strengths and limitations of the studyThe response rate was high and the backgroundcharacteristics of the participants were similar to thetotal population of GPs in Norway (11). This indicatesthat the sample is representative.

It is a strength of this study that the questionnairewas based on the findings of a previous qualitativestudy, as this should ensure the relevance of the items.However, it is a weakness that the questionnaire wasnot validated.

The GPs’ approximation of how many prescriptionsthey had issued on their last practice day mightrepresent a bias, as an under-estimation of prescribingvolumes could be expected, although anonymityshould reduce the likelihood of this. However, nounbiased method for controlling prescribing volumeswas available, as data control legislation in Norwayprohibits linking prescription data to personal infor-mation. Self-rating of prescribing has been shown tocorrespond quite well with pharmacy dispensingfigures (17).

A counting of prescriptions could have given moreprecise figures of the prescribing volumes, but due tofeasibility we chose to ask for a self-estimation in thequestionnaire. The fact that only 0.7% of all the GPsrated themselves as very high prescribers correspondswell with earlier findings: that a small number of GPsare responsible for a large proportion of the totalprescribing (4).

The outcome variable was dichotomised both tomake the interpretation of OR more clear, and toaccommodate logistic regression. This simplificationmight have been performed at the cost of detectingeffects of predictors for prescribing.

Our data do not give information about the numberof patients seen by the particular doctor, or aboutpatient characteristics. This could have given informa-

tion of how many patients were eligible for prescribing.However, as a substantial number of prescriptions arehanded out without consultation, such informationmight only have given a limited explanation of pre-scribing volumes.

ImplicationsThe findings from our study indicate that there ispotential for improvement in benzodiazepine and mi-nor opiate prescribing practice, for instance by reflect-ing on how and to what extent prescribing decisionsare influenced by patients and how experienceddifficulties influence the decision process. Better prac-tice routines could be considered as not to prescribethese drugs without consultation.

However, it is important to underline that betterprescribing practice does not just imply a reduction inprescribing, but also that patients who need treatmentare given the right medication.

ACKNOWLEDGEMENTSWe extend our thanks to the participating doctors foranswering the questionnaires, to Professor OlafAasland for help with the sample, to Associate Profes-sor Hakon K. Gjessing for statistical advice, to Asso-ciate Professor Lise Kjølsrød for valuable advice on thequestionnaire and to Associate Professor Siri Steine forhelpful comments.

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