Electronic data processing in the control of legal consumption of narcotics in Norway

Abstract

Norway has a relatively low prevalence of narcotic addicts; nervertheless individual tragedies and social and economic consequences justify the characterization of drug dependence as an important public health problem.

Details

Author: Bjorn JOLDAL , Tullik HALVORSEN
Pages: 55 to 57
Creation Date: 1972/01/01

Electronic data processing in the control of legal consumption of narcotics in Norway

Bjorn JOLDAL Director, Pharmaceutical Division, Health Services of Norway, Oslo
Tullik HALVORSEN Head of EDP Department, Norsk Medisinaldepot, Oslo

Norway has a relatively low prevalence of narcotic addicts; nervertheless individual tragedies and social and economic consequences justify the characterization of drug dependence as an important public health problem.

We may approach this problem from different angles. The epidemiological model has also been applied to drug dependence and may - correctly understood and modified-be useful. We speak about epidemics and drug abuse caused by infection, and use terms such as "strongly exposed contacts ", "carriers ", etc. The model may be of use in the planning process for action to prevent drug dependence. We are accustomed in epidemiology to distinguish between action directed to the pathogenic agents, the environment, and the host.

Under the first category one would list steps to make dependence producing drugs as unavailable as possible through restrictive measures on production and distribution.

A few examples demonstrate how the Norwegian health authorities have tried to eliminate some of the pathogenic agents:

  1. The distribution of drugs which are not medically justified - such as heroin, LSD and cannabis - is forbidden.

  2. Pharmaceutical specialities, such as dexamphetamine for weight reducing purposes, have been dropped from the register of pharmaceutical preparations.

  3. A licensing system has been introduced for the prescription of amphetamines and other stimulants, meaning that doctors have to apply for a licence to prescribe these drugs for an individual patient.

  4. The composition of certain pain killers containing barbiturates has been changed, and the barbiturates removed.

  5. Due to modification of one of the most widely used cough mixtures, the consumption of morphine decreased from 17,5 to 9 kilogrammes between 1968 and 1969.

The control system implies supervision of import, export, manufacture, production, sale and consumption.

In Norway there is a state monopoly - the Norsk Medisinaldepot (NMD)--for wholesale distribution of medicines, and the monopoly alone has the right to import and export narcotics. The sale of medicines only through licensed pharmacies (on an average 1 per 13,000 population) under inspection by public health authorities and exact recording (" book-keeping ") of all drugs covered by the Single Convention on Narcotic Drugs of 1961, create the possibility for the central public health authorities to check for each person authorized to prescribe drugs the exact amounts prescribed and, further, to check the exact consumption of the individual patient. Such controls been have carried out for years, but they were rather time-consuming and the intervals between the time the information was obtained and action was taken were considered too long.

In the beginning of 1968 the first steps were taken to establish an information system based on electronic data processing (EDP) of data from all prescriptions of narcotics, which could provide a more efficient control over legal consumption.

Primary data are collected in the pharmacies, under the guidance of, and daily contact with, the state monopoly (Norsk Medisinaldepot) which has sufficient experience and know-how in the field of data collecting and processing. NMD's EDP system already has detailed information regarding each of the 282 pharmacies, all narcotics in question (30 drugs with a total of 130 different package sizes) and also the sales figures from NMD to each pharmacy.

NMD's system is based on the following data: (1) Approximately 220,000 prescriptions a year; (2) Ap- proximately 5,500 medical doctors; (3) Approximately 3.8 million inhabitants; (4) 282 pharmacies; (5) 30 narcotic drugs (approximately 130 different package sizes).

The Norwegian Health Services (the user), representatives from the pharmacies (both collectors and users), and NMD developed in co-operation the following three types of statistics:

  1. The consumption of narcotics: ( a) per patient; ( b) per hospital; ( c) per doctor (i.e. for use in his practice or for self-medication) together with the prescribing doctor's name and that of the pharmacy, the transaction date, and the kind and quantity of drug involved.

  2. The number of prescriptions per doctor together with information on the patient and pharmacy concerned, the transaction date and the kind and quantity of drug involved.

  3. The purchase and sales figures and production wastage of each pharmacy.

Reports should be made quarterly.

Before starting the construction of the data-system, we had to answer two questions: (1) How to identify the physician and the patient in question. (2) How to construct the "input " -formi.e. the written source from which data might be obtained and registered in the EDP-system.

All inhabitants of Norway have an official individual code consisting of 11 figures. However, we did not find this code suitable for our purpose, because inhabitants are not issued an identity-card and consequently it would be too much trouble to get hold of an individual's code. We therefore constructed a patient-code based on easily available data on the patient: (1) Date and year of birth; (2) Sex; (3) The first two letters from surname and first name. An example - John Harrison 17th May 1930:

Patient-code

Birth

 

First two letters from:

Day

Month

Year

Sex

Surname

First name

17 05 30
M
HA
JO

A code built up in this way is, of course, not a 100 per cent identification-code, but it has worked satisfactorily in this project.

Since for the time being, the health authorities have not instructed the physician to put down his own individual code in the prescription form, it has been necessary to construct a prescriber-code. This had to be as short as possible since the coding of this information had to be done centrally at NMD. A code-index covering all medical doctors alphabetically together with an identification-code consisting of 5 figures was prepared. When forming the lay-out of the input, we had to take into consideration:

  1. Data would be collected in pharmacies and input ought to be coded in the same place, the work being done by many coders with only little or no experience in the field.

  2. Input must be easy to file systematically because the investigator (the health authorities) has to return to the input in order to find the name of the patient in question. (As our patient-code is not a 100 per cent identification-code, it was not possible to build up a "personal file" from which we could find the name of the patient.)

Two methods were considered: (1) To construct a standardized prescription-form; (2) To revise the existing "book-keeping" form of the narcotics register in which pharmacists are bound by law to write down data from all prescriptions of narcotics.

The second alternative was selected, and we drew up the" Narkotikablankett" in such a way that pharmacists could also record data concerning their own production wastage, breakage, etc. The system has been in operation since July 1970. Of course, some errors occurred in the input, specially in the beginning. Some of the pharmacists found the coding cumbrous, but they have now had more training and experience, and the error lists from the computer decrease from month to month.

The system produces three categories of reports. The first two are so-called "exceptional" reports, since they are only made available to the Ministry of Health. The first indicates the patients who have received prescriptions more than 3 times in the period; the second indicates the doctors who have prescribed narcotics more than 30 times in the period. The third report, which is made available to the pharmacist as well, shows the total sales, purchases, wastage/breakage and increase in stock per pharmacy during the period.

The costs of the running operation at NMD are calculated at N.Cr. 150,000 a year (approx. $20,000). The development and the programming of the system are calculated at N.Cr. 50 +,000 (approx. $7,000).

Pharmacists do not get any fee for collecting and coding data, but they do receive the report covering their own narcotic transactions free of charge. NMD has carried out both the development and the programming and also the running operation at their own expense.

It is difficult to draw final conclusions after running the project for only one year, but some preliminary results may be mentioned:

  1. First and foremost, the information provided is more complete and reliable and is obtained without delay. This permits the health authorities to act at an earlier stage than before. During the past year, we have been informed of a hundred new patients using more than one doctor for prescribing narcotics. Often a pattern can be found: patients stagger their consultations throughout the month and visit different pharmacists for each doctor. One patient visited 17 doctors and 20 pharmacists in 6 months.

    If the amount and type of drug consumed by the individual patient or the pattern of his consultations indicates a drug dependence, a confidential letter is sent by the health authorities to pharmacists and doctors. Thus, the opportunity for the drug addict to get supplies is limited. In this way one may succeed in channelling his consumption through one single doctor willing to try to control the intake of drugs and preferably motivate the patient for treatment. A few examples: a patient born in 1944 got in 6 months 1,555 ml of Ketobemidone injection and 120 suppositories of pethidine from 13 doctors and 7 pharmacies. After having informed the doctors, the patient now has to see only one doctor until she can be received in the State Clinic for treatment. Another patient, born in 1951, got in 6 months 130 tablets containing 5 mg thebaicine, 175 ketobemidone tablets and 340 ml ketobemidone injection from 9 doctors and 2 dentists. The doctors were informed and the patient sent to the above-mentioned clinic by compulsory measures. Other patients showing a similar pattern are now under voluntary treatment in the State Clinic.

  2. The consumption of narcotic drugs - or, more correctly, the sale of narcotic drugs from NMD - has decreased considerably. The sales figures for raw materials show a decrease of 10-20 per cent. As concerns the sale of pharmaceutical specialities containing narcotic drugs, the decrease has been even greater, going as high as 20-50 per cent. It is difficult to judge if this decrease indicates a former over-consumption or abuse, as no investigations have been carried out to see if there has been a corresponding increase in the use of other legal or illegal drugs. The number of prescriptions has decreased as shown below:

    Prescriptions to individual patients

     

    1st quarter 1971

    2nd quarter 1971

    4th quarter 1970 Number

    Number

    Percent decrease

    Number

    Percent decrease

    32,213 30,015 6.8 28,936 3.6

    The fact that doctors know they are watched more carefully, and that the health authorities act rapidly on the information obtained, seems to be important.

  3. An occupational risk is clearly observable. Generally about 10 per cent of the "classic" addicts are estimated to belong to the medical and related professions. One of the aims of the project was to carry out a more effective surveillance of the doctor's prescription habits.

The health authorities have information on several new doctors prescribing high amounts of narcotics for their patients or for personal use. It may be mentioned that the EDP system showed that one doctor prescribed 14,000 hydrocone tablets to onepatient during 3 months; another doctor prescribed 435 ketobemidone tablets for personal use in the same period and used 13 pharmacies for his 24 prescriptions. A third doctor, unnoticed before, ordered 4,000 ml of methadone for injection over a 6-month period. Once again, several pharmacies were contacted to obtain these large amounts.

If a doctor's prescription habits seem to be unjustified or if there is reason to believe that he himself is an addict, a letter is first sent by the health authorities asking him for an explanation. If the doctor is unable to justify his pattern of prescription, he will get a warning letter from the Director-General of the Health Services of Norway and his prescriptions will be controlled carefully to see if his attitude to the problem evolves in a satisfactory manner. The fact that his case is under observation will sometimes be enough to put the doctor back on the right track. If not, the case may be referred to a special council consisting of highly qualified judges and two doctors with wide experience in the practice of medicine. After hearing the doctor, the council has authority to deprive him of his right to prescribe specified drugs for a certain period. In most cases a similar solution can be arrived at on a "voluntary" basis. During the year 1970, 8 doctors "voluntarily" refrained from prescribing narcotics. The authorities may also bring the matter before an ordinary court with the aim of depriving a doctor of his general licence; but this procedure is only used in extreme cases.

The information system has proved successful and served its purpose so far. However, this source may be used for more detailed studies of doctor's prescription habits and for drug consumption studies. An EDP procedure is also well suited for handling the greater amounts of data which will be necessary if such drugs as barbiturates, tranquillizers, etc., are to be controlled in the same way.