Lasting improvement of medication-overuse headache after brief intervention - a long-term follow-up in primary care.

BACKGROUND AND PURPOSE: Withdrawal therapy improves the headache situation for many patients with medication-overuse headache (MOH), but relapses are common. The objective was to assess the long-term effectiveness of a general practitioner conducted brief intervention (BI) for MOH. METHODS: Sixty MOH patients initially participating in a blinded cluster-randomized controlled trial evaluating BI versus business as usual (BAU) were followed up for 16 months. Follow-up was open after 6 months. Headache and medication days per month were evaluated in three groups: BI early (BI throughout the study, n = 24), BI late (initial BAU, then cross-over to BI, n = 22) and BAU throughout the study (n = 14). RESULTS: Fifty-five of 60 initially included patients completed the follow-up. The mean change over 16 months' observation in the BI early group was a reduction of 8.4 (5.4-11.4) headache and 13.5 (9.6-17.3) medication days per month. The relapse rate into medication overuse was 8.3%. Patients in the BI late group also improved significantly after a BI. BAU showed no significant improvement. CONCLUSIONS: Treatment for MOH in primary care through a BI is a simple intervention with lasting effects and low relapse rate. This approach may be a logical first step in MOH treatment, and referral should generally be reserved for primary care non-responders.

Predictors of successful primary care detoxification treatment for medication-overuse headache.

OBJECTIVES: To investigate predictors for successful treatment outcome after a brief intervention (BI) for medication-overuse headache (MOH). MATERIALS AND METHODS: This study evaluated predictors of successful withdrawal among patients initially participating in a pragmatic cluster-randomized controlled trial with single crossover in Norwegian general practice (the BIMOH study). BI (early or after crossover) was compared to business as usual (BAU) for the treatment of MOH. Patients were followed up 3 months after the BI. RESULTS: In total, 46 patients had the chance to receive the BI (24 early and 22 after crossover) and were included in the predictor analyses. The mean reduction in headache and medication days/month from baseline for the BI was 6.9 (95% CI: 4.8-9.1) and 10.9 (8.1-13.6). The mean percentage reduction in headache and medication days was 30.5% (21.4-39.7) and 50.4% (39.5-61.3). Only five patients started prophylactic medication. Neither age, gender, co-occurrence of migraine, main type of overused drug at baseline nor Severity of Dependence Scale score at baseline predicted successful withdrawal in the prespecified analyses. Headache days/month and medication use at baseline were significant predictors in exploratory analyses with more headache and medication days predicting worse outcome. CONCLUSIONS: Brief intervention for MOH is a simple and effective intervention in primary care. As the only identified predictors were frequency of headache and medication use, we conclude that treatment for all MOH patients should be attempted in primary care before referral. A raised awareness of MOH is important, as the condition is highly preventable and treatable. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01314768.

Disability, anxiety and depression in patients with medication-overuse headache in primary care - the BIMOH study.

BACKGROUND AND PURPOSE: Medication-overuse headache (MOH) is common in the general population. Detoxification is the general treatment principle for MOH. The present paper is based on a study of a brief intervention (BI) for MOH in primary care. New data on headache disability and the Hospital Anxiety and Depression Scale (HADS) for MOH patients compared to population controls with and without chronic headache are presented and compared to previously published main outcome data. METHODS: This was a double-blind pragmatic cluster randomized controlled trial carried out amongst 50 general practitioners in Norway. The BI was compared to business as usual (BAU) and population controls, and patients were followed up after 3 months. Primary outcomes were headache and medication days per month after 3 months. Headache disability and HADS were also measured as secondary outcomes. RESULTS: Sixty MOH patients and 40 population controls were included. BI was significantly better than BAU after 3 months regarding primary outcomes. Non-intervention population controls did not change. The MOH patients had significantly higher headache disability and anxiety scores than the population controls. CONCLUSIONS: Patients with MOH are a highly disabled group where anxiety and depression are important comorbidities. Detoxification of MOH by a BI in primary care is effective and has potential for saving resources for more treatment-resistant cases in neurologist care.

Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice.

We have carried out a prospective, controlled trial to ascertain whether mailed feedback on general practitioners' (GPs) own prescribing combined with relevant recommendations on drug treatment, can improve the prescribing. The GPs in the Norwegian county of Møre and Romsdal recorded all their contacts with patients and prescriptions during two periods. After the first period the GPs in Romsdal only (intervention group) received a mailed report giving their prescribing profiles as well as treatment recommendations for insomnia and acute cystitis. The total number of contacts with patients was 68,625 in which 55,747 items were prescribed. The GPs in the intervention group changed their prescribing in accordance with the intervention: they prescribed significantly less sleeping-pills for each patient, preferred short- to long-acting benzodiazepine hypnotics and tranquilizers, and they chose trimethoprim as a first line treatment for acute cystitis. We conclude that it is possible to improve the GPs' prescribing through mailed feedback.

General practitioners' drug prescribing practice and diagnoses for prescribing: the Møre & Romsdal Prescription Study.

We have examined the prescribing patterns among general practitioners (GPs) in a Norwegian county in relation to the patients' age and sex and the diagnosis for prescribing. Altogether 69,843 contacts with patients were recorded during which 56,758 items were prescribed. The average number of items prescribed per patient contact was 0.81 (male 0.76, female 0.83). Diazepam, the compound analgesic of paracetamol (i.e. acetaminophen) and codeine, and triazolam were the three most frequently prescribed drugs for females as compared to phenoxymethylpenicillin, paracetamol/codeine and diazepam for males. Insomnia was the most frequently recorded diagnosis for prescribing. Listed second were upper respiratory tract infections (males) and anxiety (females). Hypertension was the number three diagnosis. The twenty most frequently prescribed items accounted for 48.5% of all drugs prescribed and the twenty most frequently recorded diagnoses for prescribing accounted for 61.7% of all diagnoses. This makes it possible to analyze a substantial part of the GPs' total prescribing by focusing on a few drugs or diagnoses.

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study.

AIM: Based on a multidisciplinary review of drug use in nursing home residents, this study aimed to identify the most frequent clinically relevant medication problems and to analyse them according to the drugs involved and types of problems. METHODS: Cross sectional study auditing drug use by 1354 residents in 23 nursing homes in Bergen, Norway. Data were collected in 1997. A physician/pharmacist panel performed a comprehensive medication review with regard to indications for drug use and active medical conditions. The drug related problems were subsequently classified according to the drugs involved and types of problems (indication, effectiveness, and safety issues). RESULTS: 2445 potential medication problems were identified in 1036 (76%) residents. Psychoactive drugs accounted for 38% of all problems; antipsychotics were the class most often involved. Multiple psychoactive drug use was considered particularly problematic. Potential medication problems were most frequently classified as risk of adverse drug reactions (26%), inappropriate drug choice for indication (20%), and underuse of beneficial treatment (13%). CONCLUSIONS: Three of four nursing home residents had clinically relevant medication problems, most of which were accounted for by psychoactive drugs. The most frequent concerns were related to adverse drug reactions, drug choice, and probable undertreatment.

Influence of prescription patterns in general practice on anti-microbial resistance in Norway.

BACKGROUND: The global pandemic of antibiotic resistance is causing considerable concern, and a major reason for the growing world-wide resistance problem is the overuse of anti-infective drugs, especially the use of broad spectrum antibiotics. This is still a relatively minor problem in most of the Nordic countries where the consumption of antibiotics is less than half of that reported from southern Europe and the United States of America (USA). AIM: To describe the resistance pattern among common respiratory tract pathogens in Norwegian general practice, the national consumption of antibiotics, and GPs' prescription patterns for respiratory tract infections. To offer some suggestions as to why Norway has maintained a favourable situation regarding resistant microbes during the past 10 years. METHODS: An analysis of the prescription patterns in Norwegian general practice. RESULTS: There is a low total prescription volume of antibiotics compared with other countries. Penicillin V is the most commonly used antibiotic for the most common airway diseases in general practice in Norway. CONCLUSION: Although there is a low prevalence of antibiotic resistance in Norway, there is still a great potential for reducing the unnecessary antibiotic prescribing for the most common respiratory illnesses.

Stopping long-term drug therapy in general practice. How well do physicians and patients agree?.

BACKGROUND: GPs have a particular responsibility to limit the occurrence of polypharmacy and adverse drug reactions, and to discontinue unnecessary drug therapy. OBJECTIVE: The aim of the present study was to measure the extent to which patients and physicians agree upon information communicated in a consultation when a drug is withdrawn. METHODS: A total of 272 Norwegian GPs and 272 patients filled in questionnaires after a consultation in which a long-term drug therapy had been discontinued. Their answers were compared and the agreement measured by kappa statistics. RESULTS: There was 100% concordance between physicians and patients as to what drug had been discontinued. Most of the drugs (72%) were cardiovascular. There was fair agreement as to whether the drug was to be stopped abruptly or gradually withdrawn (kappa 0.61) and whether a follow-up appointment had been scheduled (kappa 0.41). Physicians were not able to judge patients' satisfaction accurately (kappa 0.20). Most patients (73%) were satisfied or very satisfied with the decision to withdraw the drug, and many commented that good communication and close follow-up is a prerequisite for successful withdrawal of long-term drug treatment. CONCLUSIONS: Discontinuation of drug treatment was welcomed by most patients. Physicians and patients agreed completely as to what drug was to be discontinued, and fairly well about other factual aspects, but physicians were not able to judge patients' satisfaction accurately.

[From barber-surgeons' guild to medical association. A 400th anniversary]. / Fra bartskjaerlaug til legeforening. Et 400-årsjubileum.

The barber-surgeons' guild in Bergen was founded on 17 January 1597. For nearly 250 years this was the only "medical association" in Norway. The guild disappeared with the death of its latest master, Christian Wilhelm Wisbech (1740-1822). However, only nine years later his son, Christian Wisbech (1801-69), founded the Medical Association in Bergen. The barber-surgeons were craftsmen who got their education by apprenticeship. They were the medical practitioners of their times. Their empirical knowledge was more in touch with real life than was the medicine taught by the professors. This paper describes the barber-surgeons' education and work, including their conflicts with other craftsmen and doctors. During the 18th century the barber-surgeons' education was improved, and eventually was given full academic status.

Drug prescribing during direct and indirect contacts with patients in general practice. A report from the Møre & Romsdal Prescription Study.

OBJECTIVE: To describe general practitioners' (GPs) prescribing patterns during direct contacts (DC) vs. indirect contacts (IC) with respect to the patients (age and sex), diagnoses, and drugs. DESIGN: Descriptive study. SETTING: In the Norwegian county Møre & Romsdal, the GPs recorded all contacts with patients and prescriptions during two months. SUBJECTS: 69843 contacts with patients (42202 DC; 24983 IC) during which 56758 prescriptions were issued. MAIN OUTCOME MEASURES: Prescriptions (drugs, strength of tablets, amount prescribed, initial/repeat). Diagnoses for prescribing. RESULTS: 72 drugs were prescribed per 100 DC; 93 per 100 IC. The drugs prescribed most frequently during DC were CNS-drugs (19%), antibiotics (18%), and respiratory drugs (14%); and during IC, CNS-drugs (34%), cardiovascular (16%), and respiratory drugs (12%). More prescriptions during IC were repeat (IC, 79%; DC, 37%). 57% of all CNS-drugs were issued during IC (90% of which were repeat prescriptions). 25% of the antibiotics were issued during IC (70% of which were initial prescriptions). CONCLUSION: The GPs' prescribing patterns during DC and IC are different, which probably reflects that different health problems are handled during DC and IC. Prescription studies should address both settings. Our findings raise concern about the medical foundation for antibiotic and psychotropic prescribing during IC.

[Roboratio or relaxatio? Clinical theory and practice in the 19th century]. / Roboratio eller relaxatio? Klinisk teori og praksis på 1800-tallet.

The first Norwegian medical school was founded in 1814. Niels Berner Sørenssen (1774-1857), one of three professors, was responsible for teaching pathology and therapy, and for clinical education. Together with his student and successor, Andreas Christian Conradi (1809-68), he made his mark on Norwegian physicians for a period of 50 years. A few years ago a small handwritten book by a medical student, dated 1828, turned up in a second-hand market. This book, which contains notes from Professor Sørenssen's lectures on therapy, demonstrates that his teaching was heavily influenced by the speculative theories of John Brown (1735-88). Similar influence is traceable in the annual reports from Norwegian physicians during the second half of the 19th century. Sørenssen urged his students to thoroughly investigate the medical history and make a detailed clinical examination, and his attitude to therapy was careful, almost reluctant. This personal clinical attitude was probably more important than the theoretical foundation upon which he based his lectures.

[1384 house calls to elderly patients in family practice. From diagnosis-prescriptions-examination in Møre and Romsdal]. / 1384 hjemmebesøk til eldre pasienter i allmennpraksis. Fra diagnose-resept-undersøkelsen i Møre og Romsdal.

Over a period of two months in 1988 and 1989 all general practitioners in the Norwegian county of Møre and Romsdal recorded all contacts with their patients. We report data from 1,384 house calls to elderly patients (65 years and older). House calls made up 11.3% of all face-to-face contacts between general practitioners and elderly patients. 59% of the visits were to female patients, and 60% were to patients 75 years and older. 23% of the house calls took place during weekends, and new diagnoses were made in 58% of the cases. The most common groups of diagnoses were cardiovascular (21%), respiratory (16%), and musculoskeletal diseases (13%). Drugs were prescribed for 42% of the house calls. 28% of all drugs prescribed were for the nervous system, while 26% were antibiotics for systemic use. Most house calls were made because of acute illnesses. Our results suggest that preventive home visits to the elderly are rarely, if ever, performed in general practice.

Are prescribing patterns of diuretics in general practice good enough? A report from the Møre & Romsdal Prescription Study.

OBJECTIVE: To examine general practitioners' (GPs) prescribing patterns of diuretics with respect to indications, drugs and doses to reveal possible needs for prescribing audits. DESIGN: Observational, cross-sectional study. SETTING: The Norwegian county Møre & Romsdal. SUBJECTS: 1896 prescriptions for diuretics prescribed by GPs during two months. MAIN OUTCOME MEASURES: Prescriptions (drugs, strength of tablets, volume prescribed, directions for use). Diagnoses for prescribing. RESULTS: Furosemide was prescribed most frequently (48.7%) followed by the compound diuretic of hydrochlorothiazide and amiloride (26.4%), thiazides and related drugs (13.0%), and spironolactone (5.8%). Diuretics were mainly prescribed for hypertension (48.4%), congestive heart failure (35.6%), and oedemas (e.g. orthostatic) (6.1%). The patients' mean age was 69.2 years; two of three were females. When thiazides and related drugs were prescribed for hypertension, we found that the daily dose was excessive in 37.2% of the cases. In congestive heart failure, furosemide was prescribed in about four of five cases, while bumetanide was prescribed in 1.5% of the cases. CONCLUSION: Our findings indicate that GPs need more knowledge about low-dose diuretic therapy in hypertension, about different diuretic regimens in heart failure, and about non drug treatment for orthostatic oedema. Clinical pharmacology regarding diuretics should be given priority in the vocational training and continuing education for GPs.

General practitioners' prescribing patterns of benzodiazepine hypnotics: are elderly patients at particular risk for overprescribing? A report from the Møre & Romsdal Prescription Study.

OBJECTIVE: To compare general practitioners' (GPs) prescribing patterns of benzodiazepine hypnotics with current recommendations. DESIGN: Observational, cross-sectional study. SETTING: The Norwegian county Møre and Romsdal. SUBJECTS: 3452 prescriptions for benzodiazepine hypnotics prescribed by GPs for patients aged 20 years and older during two months. MAIN OUTCOME MEASURES: Prescriptions (strength of tablets, amount prescribed given in Defined and Prescribed Daily Doses: DDDs and PDDs, directions for use); initial or repeat, patients (age, sex); kind of GP-patient contact during prescribing. RESULTS: 68.4% of the prescriptions for benzodiazepine hypnotics were for women; 52.7% were for patients aged 65 or older (65+); 59.9% were issued during indirect contacts; 81.9% were repeat prescriptions. The amount of drug per prescription increased with patients' age: 65+ received on average 69.9 DDDs (76.9 PDDs) per prescription compared with 34.4 DDDs (37.1 PDDs) for young adults (20-29 years). About four of five prescriptions were for the "strong" (i.e. 1 tablet = 1 DDD) sleeping pills irrespective of patients' age and type of prescription (initial or repeat). Written directions for use were: "to be taken daily" in 55.1%, and "only if required" in 38.0% of the prescriptions. Written information on duration of "cure" was only found in one case. CONCLUSIONS: GPs' prescribing patterns are not in accordance with recommended dosage and duration of treatment; this pattern is most pronounced for elderly patients.

[Acid-related disease in the population of two Norwegian municipalities--diagnosis and drug therapy]. / Syrerelatert sykdom hos befolkningen i to sørlandskommuner--diagnostikk og legemiddelbehandling.

BACKGROUND: The introduction of acid suppressant, cytoprotective and prokinetic drugs represented major progress in the treatment of acid-related diseases. In Norway, these drugs were reimbursed by the National Insurance System (NIS) from 1986. However, even if the distribution of the various diagnostic indications for prescribing were lacking, this reimbursement was stopped in 1995. The aim of this study was to describe prescriptions for presumed licensed diagnostic indications of these drugs for a defined population, and analyse them with regard to patients characteristics, verified (endoscopic) diagnoses, and therapeutic guidelines. MATERIAL AND METHODS: All prescriptions issued in 1994 to inhabitants of Lindesnes and Mandal Municipalities (17,105 inhabitants) were retrospectively retrieved from the pharmacies and the NIS. The medical records of the local endoscopy units and roentgen laboratories were subsequently searched for information on diagnostic procedures and final diagnosis leading to the prescriptions for these patients. RESULTS: A total number of 1,128 prescriptions (87,905 DDDs) were issued to 441 patients (3% of the population at risk; mean age 63 years; 55% men), and more commonly for the elderly (for 11% of those aged 80 years or more). Diagnostic procedures were documented for 93% of the patients (upper endoscopy in 404, 92%). Diagnostic indications for prescribing were reflux oesophagitis (48%), duodenal ulcer (24%), gastric ulcer (13%), and dyspepsia with normal endoscopic findings (12%). The drugs issued were H2-receptor antagonists (59%), proton pump inhibitors (31%), and cisapride (10%). 8% of the patients were long-term users of an NSAID. Of the 441 patients, drug treatment was issued to 38 with normal endoscopic findings and to 31 patients in whom we could not document examination by endoscopy or X-ray. INTERPRETATION: This study supports that the prevalence of dyspeptic complaints calling for drug treatment increases with patient age. With minor exceptions we found that the prescribing practice for the different diagnoses is in accordance with established therapeutic guidelines.

[Benzodiazepines--quality assurance of prescriptions in own general practice]. / Benzodiazepiner--kvalitetssikring av egen forskrivning i allmennpraksis.

BACKGROUND: Even if benzodiazepines are recommended for short-term use, they are prescribed for years. Doctors often feel uncomfortable about this. MATERIAL AND METHODS: In this audit the prescription of benzodiazepines by one general practitioner was studied on the basis of the medical records, a mailed questionnaire to patients, and special benzodiazepine consultations which included diagnostic assessment. 17 long-term benzodiazepine users were given a follow-up which included general information, personal advice and alternative treatment aimed at discontinuing their use of benzodiazepines. RESULTS: 76 out of 754 patients had received prescriptions for a benzodiazepine during the previous three years. The questionnaire was completed by 63 patients. The results revealed that the treatment had originally been initiated by a general practitioner in 78% of the cases, most commonly for anxiety (40%), sleeping difficulties (23%), or depression (10%). Their doctor had previously suggested benzodiazepine withdrawal in 46% of the patients. One third were long-term users. 46% of these had used this medication more than ten years; 90% suffered from chronic illness. After 17 months, 47% of the patients had stopped using benzodiazepines while another 29% used significantly less than before. INTERPRETATION: A broad and individually tailored intervention towards patients in general practice may be a useful tool in reducing long-term use of benzodiazepines.

[10,850 general practice consultations with elderly patients. From diagnosis-prescription-examination in Møre and Romsdal]. / 10,850 kontorkonsultasjoner med eldre pasienter i allmennpraksis. Fra diagnose-resept-undersøkelsen i Møre og Romsdal.

Over a period of two months in 1988 and 1989 general practitioners in the Norwegian county of Møre and Romsdal recorded all contacts with their patients. Participation was close to 100%. We report data from 10,850 surgery consultations with elderly patients (65 years and older). 60% of the consultations involved female patients, and 58% of the patients were 65-74 years old. New diagnoses were made in one-third of the cases; two-thirds were follow-ups. The most common groups of diagnoses were cardiovascular (28%), musculoskeletal (13%), psychiatric (8%) and respiratory diseases (8%). Almost 10% of all consultations were for hypertension. Drugs were prescribed in 45% of all cases. 27% of all prescriptions were for cardiovascular drugs, and 25% were for drugs for the nervous system. The 20 most common diagnoses made up more than half of the total number of diagnoses. Almost 70% of all prescriptions were for the ten most common therapeutic groups.

[Patient encounters in general practice. An epidemiological survey in Møre and Romsdal]. / Pasientkontakter i allmennpraksis. En epidemiologisk undersøkelse i Møre og Romsdal.

In 1988 and 1989 all general practitioners (GPs) in Møre & Romsdal recorded all encounters with patients over a period of two months. The participation rate was close to 100% and a total of 90,458 encounters were recorded. Of all encounters 61% involved female patients. Female GPs had more female patients than their male colleagues (71% versus 59%). The discrepancy was most pronounced for sex-specific diagnoses. Home visits accounted for 9% of all direct encounters, an increase from the 5-6% reported in the 1970s. 37% of all contacts occurred by phone or messenger. The diagnostic distribution compares well with Olav Rutle's findings in 1978. Cardiovascular diseases, however, seem to have become less prominent since that time. The most frequent ICPC diagnoses were musculoskeletal (17%), respiratory (14%), cardiovascular (12%), and psychiatric (12%). Respiratory diseases dominated among children, musculoskeletal diseases among adults, and cardiovascular diseases among the elderly.

Withdrawing long-term diuretic treatment among elderly patients in general practice.

The aim of this study was to elaborate, implement and evaluate a strategy for discontinuation of long-term diuretic treatment in elderly patients in general practice. Thirty-three patients were enrolled for a supervised step-down and withdrawal of diuretics. After withdrawal, the patients were followed up for 6 months or until diuretic treatment was re-established. Withdrawal was successful according to the protocol in 18 cases. Diuretic withdrawal failed and the treatment was re-established in 15 cases, four of which were sudden cardiovascular events. Most withdrawal failures were identified by routine examinations through the follow-up programmes, thus they had few consequences for the patients. This demonstrates that careful follow-up is essential after diuretic withdrawal. Our findings support the view that a large proportion of elderly patients on diuretics may not need such treatment.

Drug prescribing for children in general practice. A report from the Møre & Romsdal Prescription Study.

To investigate general practitioners' drug prescribing patterns for children (0-12 y), an observational, cross-sectional study was conducted in Western Norway. Seven thousand, two hundred and twenty-nine GP-patient contacts during which 5222 drugs were prescribed, were included for analysis. The highest prescribing rates were for boys < 2 y (82.1 prescriptions per 100 contacts). Two-thirds of all prescriptions were for drugs in main groups respiratory system or systemic anti-infectives. The 20 most commonly prescribed agents comprised 75% of all prescriptions. The 20 most frequently recorded diagnoses for prescribing comprised 81% of all. Phenoxymethylpenicillin was the most frequently prescribed antibiotic for otitis, tonsillitis and sinusitis, while erythromycin was used most often for bronchitis and pneumonia. Antibiotics were prescribed in more than 8/10 contacts for tonsillitis, sinusitis, acute bronchitis and pneumonia, and in two-thirds of all contacts for urinary tract infections. Sixty-five percent of the antibiotic prescriptions for urinary tract infections were for co-trimoxazole.