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The Effects of Tranquillization:
Benzodiazepine Use in Canada
Health Canada Publication: 1982
5. FACTORS AFFECTING PRESCRIBING
Physicians are the gatekeepers of the health care system. Their actions are, of course, determined in part by those whom they find at their gates. A climate of opinion has emerged both within the medical profession and the larger society whereby persons troubled in their family, work and personal lives for whatever reasons (e.g. problems of role definition, life goals, economic pressures, chronic physical illness), find themselves in the medical clinic or the physician's office. The introduction of universal health care has made access to these services available to virtually all segments of the population. Simultaneously, lack of knowledge of the existence of other social support services, the fees charged for these services, and the residual stigma still attached to them, continues to lead individuals to seek medical attention.
Numerous factors account for the change in the types of health problems presented to the physician over the last 35 years. Increased affluence has resulted in improved nutrition, sanitation, public health measures (especially preventive services for children), the development of anti-infective agents, and higher expectations of care on the part of consumers of health care services. Concurrently, the proportion of the population over age 65 has increased markedly.
With the reduction in the incidence of acute conditions such as pneumonia and measles, there has been a concomitant increase in the range of disorders presented to the physician. It is a minority of visits to physicians now which are the result of acute conditions; the majority of visits are taken up with conditions for which treatment of a medical and/or non-medical nature may be indicated. Among these are chronic conditions, problems associated with normal aging, and physical and emotional stresses arising from common problems of living, such as work pressures, family stresses, or social isolation.
The Biomedical Model of Illness
While the nature of the disorders which doctors are called upon to treat has changed, the basic education provided by the majority of Canadian medical schools continues to be based upon a philosophical model of illness which may not be appropriate to these changed conditions. Undergraduate medical education is largely taught by specialists who tend to perpetuate the 'disease model of illness' which in its essence sees the individual body as a machine to be repaired by chemical or mechanical intervention. While courses in public health and the behavioural sciences are offered in the medical curriculum and do not follow this biomedical model of illness, these courses represent a small percentage of total course offerings. As a result, medical education continues to be primarily oriented to the identification and treatment of disease through the use of technology. Surgical and pharmacological intervention are the primary modalities of care offered patients.
Students entering general practice or certain specialties such as psychiatry may be exposed, by instructors as well as patients, to a broader concept of illness such as that developed by Engel, one which includes psychosocial factors in addition to mechanical malfunctioning. This bio-psychosocial model takes into consideration psychosocial factors such as family disruption, stress at work, isolation of the aged. Hence the use of an additional treatment technique by physicians such as counselling for emotional problems may be utilized, and occasionally referral may be made to community counselling services. While such an approach recognizes the connection between mind and body, the location of the problem and hence its treatment is still presumed to lie within the individual.
Given this medical education, virtually all physicians today are trained as scientific problem-solvers rather than carers. With its emphasis on treating disease, this training basically minimizes prevention and tends to encourage physicians to focus on the malfunctioning organ or body system, rather than on the whole person within her/his social setting. For example, the definition of excessive consumption of alcohol as a disease has led to a greater emphasis on treatment and the search for cures for the end states of alcoholism (e.g. cirrhosis of the liver) than on the doctor's role as a preventive agent. The latter would involve learning the role of alcohol in the lives of patients, history-taking which would include information on the quantity consumed, factors influencing use, and so forth. More time is allotted in our medical schools to teaching treatment of the physical damage caused by alcohol than to teaching skills which will aid in the identification and early intervention with patients misusing alcohol.
This emphasis on treatment may also account for a great deal of the frustration felt by physicians in their contacts with the elderly and the chronically ill for whom high technology medicine holds few significant answers. There is at present a mismatch between the skills and training of physicians and the majority of problems seen in practice. With the growing elderly population this problem will become more severe.
The continuing emphasis on the biomedical model of disease tends to minimize expenditures on preventive services. This is evidenced by the high proportion of our total health budget spent on costly high technology equipment located in hospitals.
The tendency to define all problems seen by the physician as having their source solely within the body or mind of the individual has profound implications for the prescribing of benzodiazepines. Social problems, often felt and expressed by the individual as emotional pain or distress, are commonly defined as psychological symptoms of a disease process.*
Once so defined, such a problem requires health care resources and active treatment by the physician. This treatment often takes the form of a benzodiazepine prescription. Such prescriptions can result in short-term positive consequences for the individual and the physician. In the case of some types of disordered sleep problems the use of a benzodiazepine for a few nights may provide a satisfactory solution. In the case of incapacitating anxiety, short-term benzodiazepine therapy may also provide enough immediate relief to permit counselling or other relevant interventions. It may also be the support, concern and time provided by the physician in the course of a visit which provides a measure of short-term relief. The patient may benefit through being relieved temporarily of difficult or burdensome obligations by being perceived as sick, thus experiencing diminished family responsibility, time off work, and increased sympathy. In such situations the doctor feels she/he has done something for his patient and thus relieves the doctor's frustration; simultaneously, by the giving of a pill the doctor's and the patient's belief that the locus of illness resides in the individual is reinforced.
While benefits from short-term drug use may clearly be seen, the underlying social problems causing the anxieties may be untouched by the continued use of medication and left ultimately unattended. The drug may, in fact, by masking the patient's feelings, diminish motivation to act. Continued use of benzodiazepines can also result in increased dependence both on the individual physician and frequently on institutions such as hospitals. In addition to the economic costs incurred by continuous use of physician services there may be a range of other costs to the patient. These could include a lessened sense of competence, lowered self-esteem, and a self-definition as 'sick', all of which may result in an inability to pursue resolution of his/her problems.
Physicians who continue to prescribe psychotropic drugs to patients presenting with such complaints are inadvertently transforming social problems into medical ones. In giving a drug the physician conveys the message to the patient that s/he has identified the problem, that the patient came to the proper place for treatment, and that it is the physician, not the patient or other segments of the community, who needs to take action or be involved. Through giving a drug, the physician defines the patient's discomfort as amenable to a medical solution, is satisfied that s/he has acted on the problem, and reduces the patient's anxiety by accepting responsibility for treatment.
Because of their training, physicians are likely to prefer to work with patients whose symptoms are definite and with whom, by applying their knowledge, they can facilitate healing. They frequently complain of the high proportion of patients appearing with 'vague' and 'trivial' complaints. Because of the frustrations in this situation, the administration of a drug, even when based on the assumption of a partial placebo effect, may reduce the physician's feeling of helplessness.
These frustrations arise, in part, from the fatalistic view held by the doctor that there is nothing s/he can do to alleviate or change an unpleasant life situation. Some of the great variation in prescribing of psychotropic drugs may be accounted for by the individual physician's philosophic view of his/her potential as a change agent, as well as by temperamental differences and variations in training. That is, some physicians, feeling there is little they can do to effect change, prefer not to discuss social stresses and may actively discourage such discussion on the part of patients. Such physicians may view insomnia as a legitimate basis for prescription of a sleeping medication, at the same time refusing to examine possible psychosocial bases of the sleep disorder.
On the other hand, physicians who recognize the relationship of social strains to the anxieties presented may either realize that chemical intervention is of little use in altering poor life situations and consequently use these drugs minimally, or feel that the drugs may provide temporary relief and consider it more humane to provide them as a coping mechanism.
The variation in attitudes and beliefs regarding the prescription of these drugs has been strikingly demonstrated in a study conducted during 1977 by the Birmingham Research Unit of the Royal College of General Practitioners in Britain. The study found wide variation among family doctors in the rates at which psychotropic drugs were prescribed, to the extent of "a tenfold difference in the use of these drugs (40 per 1000 compared with 415 per 1000). These variations, perhaps more than anything else, illustrate the interplay of the many factors discussed above.
Organization of Medical Care
As with the biomedical model, the structure of health care services bears examination as it may affect prescribing patterns. Organizational features of our health care system and methods of financing it have been shown to influence many patterns of medical practice, such as rates of surgery and hospitalization. The following section will review the effects on prescribing of method of physician payment, size of practice, utilization review, and third-party payment for prescriptions. It frequently has been assumed that method of physician payment would influence the rate of drug prescribing by permitting salaried physicians more time with patients than those working on a fee-for-service basis. Unfortunately, large-scale studies comparing the prescription rates of physicians paid by fee-for-service with those paid by salary or capitation are not available. One recent Canadian study has attempted an analysis of this issue through the use of simulated cases. The study presented physicians with a simulated case of tension headache for which diazepam had been prescribed for the past year. Physicians in group practice working on a fee-for-service basis in the Montréal area were compared to salaried physicians practising in health centres. The findings showed little difference in the proportion of physicians willing to prescribe diazepam. However, the salaried physicians imposed stricter time limits on their prescriptions, issued clearer warnings about drug use, and were more likely to suggest non-chemical therapies. The salaried physicians also spent a longer time with the patients which may be the major factor accounting for the differences found in their approach to prescribing.
The limited studies available in the literature suggest that physicians practising in group settings generally prescribe drugs more appropriately than physicians practising alone. Although no Canadian studies exist on this topic, two American studies of patients receiving care from group practices found fewer drugs of all kinds prescribed, including tranquillizers, sedatives and hypnotics.[115,116] While it is possible that practitioners in group practice are more skilled, or that differences in patient populations utilizing such practices explain some of the findings, it seems reasonable to conclude that practising in a group encourages discussion and continuing education on issues in medical care and thus may be an important factor associated with the quality of prescribing.
Group practices can permit the utilization of a wider variety of personnel, such as social workers, public health nurses, and nurse practitioners. The effect of introducing nurse practitioners as primary care workers in a family practice setting was assessed in a Canadian study and it was found that the use of nurse practitioners in contrast to traditional nursing staff clearly reduced the number of tranquillizing drugs prescribed.
Group practice is, of course, not an automatic guarantee of high quality prescribing. Another factor affecting prescribing may be peer review. Periodic review of prescribing patterns has been proposed and partially adopted in a number of countries as a means of assessing and ultimately improving prescribing quality. Pressure for such reviews has come from within government agencies as well as from the leadership of some medical groups such as the College of Family Physicians of Canada and the Royal College of General Practitioners in the United Kingdom. In the simplest form of such review, a physician may audit his/her own prescribing practices and compare this to what s/he deems appropriate, or to a pre-established norm. A potentially more valuable process is that in which a group of practitioners jointly review their prescribing practices and thus benefit collectively from a wider array of clinical experience. Finally, computerized prescription records of large populations may be used in utilization reviews.
One self-audit was conducted in a rural, northern Ontario practice. The author aimed to review his own prescribing habits to learn for what types of patients he prescribed which drugs, to relate drug use to illness and to test a new method of reporting and measuring drug use. Through this analysis the author was able to compare his prescribing patterns and practices with that of many larger practices, thus deepening his understanding of his own behaviour. In his words, "A study of prescribing is a revealing exercise, which tells one more about the doctor than about his patients."
Peer reviews in group settings are considerably more frequent than self-audits. A study of the educational value of assessing prescribing of psychotropic drugs was conducted in an Irish group practice. They found, for example, that a disproportionate number of patients were receiving psychotropic drugs on repeat prescriptions, a situation which they considered undesirable.
To assess drug utilization by large populations computerized prescription records are necessary. Such records may make it possible to study trends in prescribing, link different rates of prescribing to either physician or patient characteristics, identify particular high prescribers and consumers, examine prescription refill practices and finally, examine the relationship between drug taking and diagnosis.
Several Canadian provinces already have or are in the process of computerizing prescription records for that part of the population which is eligible for drug insurance benefits. Saskatchewan, which provides drug insurance for all provincial residents and has computerized all prescription records since 1977, has been able to study the utilization of tranquillizing drugs in the entire population. This monitoring has provided a means of educating all physicians. It has also permitted the identification of exceptionally high prescribing physicians and will provide ongoing information on shifts in prescribing patterns over time. Among other benefits, this continuous monitoring will facilitate the analysis of the impact of any drug education programs in the province.
Various professional associations of pharmacists have accepted a more active educational role for their members with regard to prescription review. This would include checking for excessive quantities, potential drug interactions, and adequacy of instructions to patients. All of the above would protect consumers and further assist physicians in appropriate prescribing. Saskatchewan, through the cooperation of the Colleges of Medicine and Pharmacy and the provincial pharmaceutical and medical associations, has developed a drug information service that has been in operation since 1974. The service is now available to all pharmacists and physicians in the province and is well utilized.
There is some evidence to suggest that when prescriptions are insured, utilization of drugs increases.[121,122] It has been demonstrated that surgical rates for discretionary procedures increased with the introduction of insurance plans. Similarly, it may be that drug insurance would have its greatest impact on the utilization of medications for conditions which are not life threatening, such as those for which the benzodiazepines are prescribed. This was, in fact, demonstrated in a U.S. study examining prescriptions before and after the introduction of Medicaid, including medication insurance. Not only did drug utilization per patient almost double but, more important, the number of different drugs used increased, as did the average quantity prescribed. Anti-anxiety agents comprised four per cent of the top 40 drugs in the pre-insurance period and almost 10 per cent after the introduction of insurance.
A recent study in Britain appears to substantiate the above findings by demonstrating their converse. It shows that as the charges for individual prescriptions have increased, the total number of prescription sales have declined.
While the data suggest that insurance for medication raises utilization rates and increased costs diminish rates, the question remains whether the increase in use following insurance introduction results from meeting previously unmet medication needs. Additionally, it is important to learn how much prescribing results in unnecessary or excessive use once cost constraints are removed. Lack of insurance may prevent some patients from acquiring essential drugs. However, the benzodiazepines cannot be considered life-saving or as a rule essential.
Drug Promotion and Advertising
Canadian prescribing patterns cannot be fully understood without an examination of the role of the pharmaceutical industry. The industry currently supports a wide assortment of promotional activities in addition to the drug advertisements appearing in medical journals and those mailed in bulk to all physicians.
The effect of drug promotion and advertising on consumption of benzodiazepines are of concern to researchers and physicians in many parts of the world. For example, in his foreword to a publication of the Royal College of Psychiatrists, Professor Griffith Edwards recently wrote: "...I would make a strong plea for a line of research which is willing to examine the social and 'political' processes involved, rather than the focus being exclusively on the drug-using individual. We need to know very much more about the role of marketing and advertising in the burgeoning sale of these substances both in urbanized and developing countries."
There is little doubt that the industry in Canada, as elsewhere, expends considerable time and money informing physicians of its products. At issue is the degree to which physicians do, and should, rely on the industry as their primary source of information on drugs. A second concern is the quality of the information disseminated. In recent years there has been a steady increase in the number of hours devoted to the teaching of pharmacology and clinical pharmacology in Canadian medical schools. Consequently, young Canadian physicians today can be expected to be more sophisticated in their approach to therapeutics. Unfortunately, however, there is little data available on sources of information used in the decision to prescribe. While change may well be occurring, the most recent studies in developed Western nations indicate that advertising and promotional materials are still central in the decision-making process.
The range of promotional activities includes direct mail advertising, expensive educational brochures and materials, and various gifts. In addition, the industry frequently sponsors major academic meetings, supports the publication of the proceedings of such meetings, and actually supports most of the drug research conducted.[129,130]
In addition to these activities perhaps the most common sources of information for the practising physician are drug company representatives, popularly called 'detail men'. The function of these representatives is to visit individual physicians, hospital pharmacies and other prescribing institutions to inform them of new products provided by their company, new indications for use for older products, and to generally encourage acceptance of their company's products. Research conducted in the United States, the United Kingdom and the Scandinavian countries all concluded that practising physicians are reliant on detail men as a major source of information.[131-133]
It appears that the ratio of detail men to physicians varies markedly by country, with the Third World countries having the highest ratio and the more developed countries, particularly those in Europe, having the lowest ratio. For example, there was a ratio of one representative to three physicians in Brazil and one to 32 in Norway between the years 1970 and 1974.
This same study examined the function of drug company representatives and concluded: "the companies regard detailing more as selling than as public relations. If detailing gives valuable pharmacological information, it is often only a by-product, used as a method of selling. The success of the representative is measured by the volume of sales, and not by improvements in the knowledge of physicians."
In view of the significant role played by the pharmaceutical industry as a source of information, attention must turn to the quality of the information dispensed. A study of drug advertisements in both British and American journals found that the British advertisements seldom included information about drug interactions, contraindications, adverse reactions or mode of action. Advertisements in the American journals generally provided more information but still contained inadequate data for clinical judgment. Advertisements in medical journals are frequently structured to appeal to physicians on an emotional basis through the illustrations, although the text and heading might stress factual information.
Beyond a lack of information, advertisements directed to physicians have been criticized for their presentation of erroneous assumptions or false stereotypes. Psychotropic advertisements in particular have been found to encourage diagnosis 'at-a-glance'. They tend to promote extension of the definition of medical problems to encompass the stresses of daily living, and to further the belief that certain illnesses must be 'coped with' through continuous drug consumption. Several studies have demonstrated negative stereotyping of women and the elderly in drug advertisements, showing them as misfits who require drugs to endure, not change, their situations.[139-141]
* For example, the elderly, chronically ill and women commonly experience poverty, poor housing, isolation and loneliness, inadequate work environments and opportunities, and so forth.
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