We thank our correspondents for their remarks. Dr. Hummel rightly points out the role of GPs and the discrepancy between trust and insufficient information on the duration of drug treatment and the risk of dependency in Z-drugs and benzodiazepines. The decrease in prescriptions is, however, put into perspective in view of the private prescriptions that Dr. Schubert points out. Undoubtedly, Dr. Wörz is correct to mention the great effort involved in managing relevant groups of patients properly.
Furthermore we are grateful to Dr Schubert for her clarification, that the DDDs correspond to the assumed mean daily doses for the main indication. This is particularly relevant for opioid analgesics, since the therapeutically necessary dose for a pain patient may differ notably from the DDD, depending on the disease. In benzodiazepines and Z-drugs, this problem is of lesser importance, as the dosages recommended for “non-restful sleep/sleep disorders” in the S3 guidelines (1) mostly correspond to the DDDs.
The phrase “Prevalence of prescriptions . . .” in the title of Table 1 in the article refers, as explained in the legend to the table, to the proportion of patients who received a particular active substance in the relevant year, relative to all patients in the substance group (2).
Furthermore, a critical comment relates to the fact that because of the incomplete coverage of pharmacies, generalizing statements are possible to a limited degree only. Because of the weighting we undertook, these limitations are likely to have only minor effects on the results of the analysis, as it is unlikely that pharmacies with far above or far below average amounts of drugs dispensed were systematically not included in the dataset. Analyses based on data from large pharmaceutical data centers also have the substantial advantage that evaluations are done in a timely manner and across all health insurance funds. Setting up annual monitoring would thus be feasible at a justifiable effort and expense.
Wörz notes that many studies criticize the long-term use of benzodiazepines, Z-drugs, and opioid-analgesics, but do not offer suggestions for alternatives. As regards benzodiazepines and Z-drugs, however the relevant S3 guideline includes several options for helping affected patients with sleep disorders without the use of hypnotic drugs. Opioid analgesics need to be considered in a more differentiated manner. As regards chronic non-tumor disorders, the S3 guidelines (3) recommend a prescription period of more than three months for very few indications. However, for many patients with chronic pain, and even more so for patients with cancer, there is no alternative to the long-term use of opioid analgesics. We unreservedly agree with the argument that in such cases, ethical considerations take priority.
On behalf of the authors:
Dr. phil. Sven Buth
PD Dr. phil. Uwe Verthein
Zentrum für interdisziplinäre Suchtforschung der Universität Hamburg (ZIS), Universitätsklinikum Hamburg-Eppendorf, Klinik für Psychiatrie und Psychotherapie
Dr. med. Rüdiger Holzbach
Klinik für Psychiatrie, psychotherapie und Psychosomatik, Klinikum Hochsauerland
Conflict of interest statement
PD Uwe Verthein received delegate fees for conferences as well as travel expenses from Mundipharma and Camurus. He received lecture fees from Mundipharma.
The remaining authors declare that no conflict of interest exists.
|1.||Riemann D, Baum E, Cohrs S, et al.: S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen. Somnologie 2017; 21: 2–44 CrossRef|
|2.||Buth S, Holzbach R, Martens MS, Neumann-Runde E, Meiners O, Verthein U: Problematic medication with benzodiazepines, “Z-drugs”, and opioid analgesics—an analysis of national health insurance prescription data from 2006–2016. Dtsch Arztebl Int 2019; 116: 607–14 CrossRef PubMed Central|
|3.||Reinecke H, Sorgatz H: S-3-Leitlinie LONTS. Der Schmerz 2009; 23: 440–7 CrossRef MEDLINE|