Sales statistics in the control of drug abuse in Norway

Sections

Introduction
Availability of sales data
Material and methods
Sales of addictive drugs from Norsk Medisinaldepot
Sale of narcotic drugs from the pharmacies
Prescribing of narcotic drugs by doctors
The patients
Control measures by the health authorities

Details

Author: B. JØLDAL, I. HALVORSEN
Pages: 57 to 68
Creation Date: 1982/01/01

Sales statistics in the control of drug abuse in Norway

B. JØLDAL
Director, Pharmaceutical Division, The Health Services of Norway, Oslo I. HALVORSEN
Drug Inspector, The Health Services of Norway, Oslo

Introduction

In Norway, the sale of narcotic drugs has been subject to rigorous control for many years. In July 1970, a monitoring system for the legal prescription and use of narcotics was introduced. It was based on computerized prescription data collected in pharmacies throughout Norway. The aim of the system was to obtain a compote, rapid and detailed picture of prescription and consumption patterns in Norway. It covered all substances listed in the 1961 Single Convention on Narcotic Drugs [ 1] and, in addition, amphetamine and other central stimulants.

The computerized data covering information obtained from prescriptions for narcotics are available only to the health authorities.

The other dependence-producing drugs, such as tranquillizers, sedatives and hypnotics, are not covered by this particular scheme; however, in the case of narcotics, a prescription valid for only one delivery. Since the end of 1979, prescriptions for these substances, after being filled, are retained by the pharmacies for one year and are available to the health authorities upon request.

Availability of sales data

In Norway, there is only one wholesaler of pharmaceutical products, the government enterprise known as Norsk Medisinaldepot, which has the sole right to import and distribute medicines to the pharmacies. This system provides a unique opportunity to compile comprehensive sales statistics for all pharmaceutical products sold legally.

The computerized sales data may be given for single drugs or for drugs grouped according to the anatomical-therapeutic-chemical classification system (ACT) [ 2] , which is common to all the Nordic countries and is recommended by the World Health

Qrganization (WHO) for use in drug utilization studies. The quantity of drugs sold is given in defined daily doses (DDD) as the unit of measure for comparing drug-sales data.

The DDD is established on the basis of the assumed average dose per day of the drug used on its main indication on adult patients [ 2] . For many years, sales data from Norsk Medisinaldepot has been made available to the health authorities and others for the purpose of drug utilization studies etc. Since 1978, Norsk Medisinaldepot has published such data in a statistical yearbook [ 3] .

Material and methods

A detailed outline of the monitoring system covering narcotics was published in 1972 [ 4] , and results from the first five-year period have been reported [ 5] , [ 6] .

This study covers narcotics and other addictive drugs and is based on sales statistics from Norsk Medisinaldepot during the period 1970-1980, prescription data on narcotics for the period 1970-1980 and some practical results from an investigation of pharmacies, files of prescriptions from the period 1980-l981.

Reports covering the sales of narcotics are provided quarterly by the computer system. Previous studies have revealed that sales during the fourth quarter are close to the average quarterly sales each year. Accordingly, data from the fourth quarter have been used both to describe development profiles and to make more detailed studies.

The DDD was incorporated into the computerized system monitoring the sales of narcotic substances in 1975 and was then implemented as an additional criterion in the selection of both patients and doctors to whom particularly large amounts of drugs were delivered from the pharmacies.

Sales of addictive drugs from Norsk Medisinaldepot

Analgesics containing narcotic drugs

The development from 1972 to 1980 is shown in figure 1. There was a substantial reduction in the total sales from 1975 to 1976. This reduction was mainly due to the introduction of an authorized standard prescription form, which was an attempt to reduce the existing problem with stolen and falsified prescriptions. It was not an attempt to reduce the consumption of narcotics.

The sales curve for methadone (figure 1) shows a marked decline from 1975 to 1976. In July 1974, an information letter, sent to all doctors, pointed out that the prescribing of methadone for young addicts in general practice was not considered justifiable. In July 1976 it was decided to limit the use of methadone to hospitals only. The result of these measures is reflected in the sales curve. From January 1980, methadone could be prescribed by hospital physicians to out-patients, mainly in the treatment of cancer.

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It may be noted that the sale of morphine in combination with other substances (except morphine and spasmolytics) is no longer legal. This is the result of a conscious registration policy in which several preparations containing more than one drug have been reassessed. Some of the preparations have been removed from the market, while the composition of others has been altered so as to exclude narcotic substances.

Pentazocine and dextropropoxyphene

When sales of analgesics containing narcotics were substantially reduced, an increase in the sale of products containing pentazocine and dextropropoxyphene was anticipated. The increase, however, was less than expected. In the case of dextropropoxyphene, the reason was partly that a warning was sent to doctors towards the end of 1975, informing them about the risk of intoxication (figure 2).

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Tranquillizers, barbiturates and other sedative-hypnotics

Figure 3 shows the trends in sales of sedative-hypnotics and tranquillizers over the period 1970-1980. Within these groups. there are small changes in the total sales (figure 4). We see that the sales of barbiturates have been substantially reduced together with some non-barbiturate and non-benzodiazepine sedative-hypnotics containing such substances as methaqualone, glutethimide and meprobamate. On the other hand, the sales of benzodiazepines (fIurazepam, nitrazepam and flunitrazepam) have increased.

As mentioned earlier, new regulations governing the prescription of these substances came into force at the end of 1979.Additionally, the registration authority for pharmaceutical specialities, the Specialities Board, decided to reduce the number of barbiturates available. The preparations containing the following four barbiturates were therefore de-registered by the Specialities Boards as of 1 April 1980: amobarbital, cyclobarbital, pentobarbital and secobarbital. The same applies to methaqualone. Glutethimide has been voluntarily withdrawn by the producer.

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A comparison with other Nordic countries shows that the consumption of tranquillizers has been 25 per cent higher in Norway than in Finland and Sweden, but considerably lower than in Denmark and Iceland. With the reduction which occurred last year, the consumption within this group of drugs is now comparable with Swedish figures.

Sale of narcotic drugs from the pharmacies

From figure 5 it may be seen that the total number of prescriptions to out-patients has decreased steadily during the period 1970-1980. From 1975 to 1976 the number of prescriptions was reduced by nearly 50 per cent, mainly because of the introduction of standard prescription forms and restrictions on the prescription of methadone. It is also noteworthy that an estimate based on a sampling in 1969 indicated a total number of prescriptions that year that was approximately twice the number in 1970. Also, the total sales of narcotic drugs decreased during the period, and the monitoring system contributed to that development.

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Prescribing of narcotic drugs by doctors

The number of doctors issuing more than 30 prescriptions per quarter has decreased from year to year. At the end of 1978 and 1979, the number was less than 10 per cent of the comparable figure for 1970. In 1975, the selection criteria for the category of doctors prescribing great quantities of narcotic drugs was changed. Those doctors who prescribed more than 500 DDD on 30 prescriptions or less were included in this category. As a consequence of this change, the number of doctors in this category increased slightly but the trends remained the same and, as figure 6 shows, the problem has been reduced to a minimum.

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At the beginning of the 1970s, elderly doctors were more frequently represented than their younger colleagues among those who wrote more than 30 prescriptions per quarter. The present study shows that the prescriptions are now more evenly distributed among the different age groups.

While the previous five-year study revealed great differences in the geographical distribution of doctors who frequently prescribed narcotic drugs, such doctors are now few in number and are evenly distributed throughout the country (figure 7).

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The patients

Figure 8 indicates the age distribution of patients who received more than three prescriptions for narcotic drugs per quarter. From 1975 all patients with more than 75 DDD in three prescriptions or less are also included.

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The total number of patients has been steadily declining. While the number of patients in the lowest age group increased from 1970 to 1975, there has been a substantial decrease since then. This reduction is obviously related to the restrictions imposed on methadone prescription in 1976.

Some other data on the patients is shown in the table. Among elderly patients the prescriptions are evenly divided between men and women, while men are in the majority in the lower age groups.

When the monitoring system started to operate, many new patients were using more than one doctor for prescribing narcotics. A pattern was often found: patients staggered their consultations throughout the month and visited a different pharmacy for each new prescription. This problem is now significantly reduced (see table).

Number, sex and prescription acquisition Pattern of young and elderly out-patients receiving more than three prescriptions in the fourth quarter of selected years

Number. sex and prescription acquisition pattern of young and elderly out-patients receiving more than three prescriptions in the forth quarter of selected years

 

1970

1974

1976 a

1979 a

Item

Young

Elderly

Young

Elderly

Young

Elderly

Young

Elderly

Number in age group b
21 238 68 181 33 114 27 66
Sex ratio (%)
         
 
 
 
Male
48 56 66 50 79 46 78 50
Female
52 44 34 50 21 54 22 50
Percentage of patients receiving prescriptions from:
 
 
 
 
 
 
 
 
One or two doctors
57 81 60 91 85 90 81 92
More than two doctors
43 19 40 9 15 10 19 8

aIncluding patients receiving more than 75 DDD in three prescriptions or less.

bAge range in groups: young 19-29; elderly, 60-69.

The geographical distribution of the patients was not investigated in this study, but as the number of patients using more than one doctor is of minor importance, there is every reason to believe that the distribution of patients is comparable to the distribution of doctors (figure 7).

From 1972 to 1976, methadone was the drug of choice among young patients: in the fourth quarter of 1974, 85 per cent of all prescriptions issued to this age group were for methadone. It now appears that ketobemidone is one of the drugs most frequently used by out-patients, whatever their age.

Control measures by the health authorities

The quarterly computer reports covering prescription data of narcotics per individual doctor and patient are routinely scrutinized by the health authorities.

In 1980 and 1981 approximately 100 doctors' prescriptions for addictive drugs such as tranquillizers, hypnotics and sedatives and some analgesics were scrutinized by calling in their prescriptions from the pharmacies' files. The selection individuals for control was mainly based on information from country medical officers, pharmacy-owners, police and patients or their relatives.

Doctors who are suspected of indiscriminately prescribing addictive drugs (e.g. to the very young or to many different patients, or who themselves require large amounts of drugs for their own practice) are requested to give an explanation to the authorities. If they are unable to justify the amounts required, a warning is issued to them. Their prescriptions are then closely monitored for a set period. If there is no improvement, their case may be referred to a special board with the power to deprive them of their right to prescribe addictive drugs.

From July 1970, when the particular monitoring system covering narcotics was introduced, and until the end of 1980, about 50 doctors voluntarily relinquished their right to prescribe narcotics. Some of them were addicts themselves.

If the amounts and type of drugs consumed by the individual patient or the pattern of his consultations indicates a drug addiction, e.g. visiting different doctors, a confidential letter is sent by the health authorities informing pharmacies and doctors in the area. Thus, the opportunity for the drug addict to get supplies is limited. The patient will normally be referred to a single doctor, who primarily would motivate the patient for treatment of the addiction and eventually prescribe the necessary drugs for a transitional period. With regard to narcotic drugs, the problem has been reduced during the period, but for the other addictive drugs it is an increasing problem.

From the present study it appears that the great majority of doctors are cautious about prescribing narcotic drugs. Besides the monitoring system, information to doctors and mass media focussing on drug dependence have contributed to changes in the prescribing pattern.

If, or to what extent, the monitoring system may result in a hidden under-consumption is difficult to say. It should be underlined, however, that the monitoring system is not intended to hinder the prescribing of such drugs for patients who really need them.

Data from the monitoring system, together with overall sales data, provide a good basis of information on drug use. If necessary, the health authorities may introduce new control measures or consider corrections of existing procedures. That involves, for example, reassessing certain preparations; introducing particular licensing procedures; promulgating additional regulations for prescribing addictive drugs and handling prescriptions; and providing information to doctors and other health personnel on particular problems.

The computerization of prescription data and the pharmacies, files on prescriptions is only one approach to the control of addictive drugs, but it has proved useful in correcting the doctors' prescribing habits and providing early and reliable information on the users of these drugs.

At present, the consumption of narcotics seems to correspond to adequate medical use. Nevertheless, due to the serious consequences of drug abuse, the computer system will be maintained. On the basis of experience gained in the past years, more attention will be paid to the monitoring of prescription and use of tranquillizers, sedatives and hypnotics.

References

001

United Nations 1961 Single Convention on Narcotic Drugs, United Nations, New York, 1977 (Sales No. F.77.XI.3).

002

The Nordic Statistics on Medicines 1975-1977, Nordiska läkemedelsnämnden, ed. (Stockholm, Nordic Council of Medicines).

003

The Drug Consumption in Norway. Norsk Medisinaldepot, ed. (Oslo, 1970-1980).

004

T. Halvorsen and B. og Jøldal, "Electronic data processing in control of legal consumption of narcotics in Norway", Bulletin on Narcotics, (United Nations publication) vol.24, No. 1 (1972), pp. 55-57.

005

T. Halvorsen, T. Haraldseid and B. og Jøldal, "Narkotikaforskrivning og forbruk i Norge 1970-1974", Tidsskrift for Den norske Laegeforening, vol. 31, (1975), pp. 1765-1770.

006

T. Halvorsen and B.og Jøldal, " Sates statistics in the control of narcotic drugs in Norway", Paper presented at the 37th International Congress of Pharmaceutical Sciences of International Pharmaceutical Federation, The Hague, The Netherlands, 5-9 September 1977.