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Benzodiazepines are probably prescribed too often to people with substance abuse problems. The drugs often alleviate symptoms effectively on a short term, but pharmacodynamic interactions and development of dependence cause problems. Indistinct, but important side effects might be overlooked or misunderstood. Evidence-based practice should replace prescriptions based on unclear indications.

Background: The large increase in sales of the benzodiazepine-like hypnotics (z-hypnotics) zopiclone and zolpidem over the last decade prompted an investigation into Norwegian general practitioners' prescription habits, knowledge of and attitudes to these drugs., Material and Methods: A questionnaire was distributed to all 928 registered GPs in six Norwegian counties. The physicians were asked to assess statements, patient vignettes and drug preferences with regard to z-hypnotic and benzodiazepine prescription practice. The responders were anonymized and grouped with respect to gender, county, years of professional experience, knowledge and attitudes., Results: A total of 321 (36%) of the GPs responded. Among the respondents, physicians with adequate knowledge about clinical use of and restrictive prescription attitudes towards z-hypnotics and benzodiazepines prescribed these drugs with a lower frequency. Prescription rates did not vary as a function of sex, geographical localization, work experience or knowledge about drug pharmacodynamics. A total of 56% of the respondents preferred zopiclone to zolpidem, whereas 8% preferred zolpidem. Many of the factors, which were used to justify the preferences, were irrelevant or erroneous., Interpretation: The study revealed a lack of factual knowledge about these drugs, and may suggest that a rational prescription practice is restrictive.

Benzodiazepines and the benzodiazepine-like z-hypnotics (zopiclone, zolpidem, and zaleplon) have the same mode of action and many of the same effects. The use of z-hypnotics has had a steady and large increase since their introduction in Norway, and sales data suggest extensive use among the elderly. The relatively short half-lives of these drugs may cause less hangover effects, but z-hypnotics are hardly more effective or safer than benzodiazepines. The two classes of drugs should be prescribed with similar caution.

Background: Psychiatric disorders occur both during pregnancy and postpartum. The consequences of inadequate treatment in these periods can be dramatic, not only for the mother but also for the infant. The reference books and textbooks used in Norway provide very scanty information on the treatment of psychiatric disorders during pregnancy and postpartum. The use of drugs is a particularly difficult issue, as detrimental effects may arise in the fetus and in the suckling infant., Material and Methods: This article is based upon a review of relevant literature supplemented by our own experience in the field., Results and Interpretation: In general, the effect is better documented for drug treatment than for other therapeutic modalities. Some drugs can be used without particular problems during pregnancy and lactation while others have potentially detrimental effects. Often the risk of not giving the mother adequate treatment must be weighed against the potential risks of drug exposure to the infant. Pregnancy-related psychiatric illness would, when recognized, in most cases have a favourable prognosis provided that adequate treatment is given.

Background: Valeriana is a herbal over-the-counter drug, in Norway mainly used for insomnia. It is estimated that in Norway only, annual sales of valeriana amount to NOK 20 m. With this considerable consumption in mind, we wanted to review the scientific basis for valeriana as a sleep aid., Material and Methods: Through a literature search we identified 18 experimental studies examining the effects of valeriana on human sleep., Results: The majority of studies reported positive effects of valeriana on subjective sleep parameters. Objective sleep measures yielded inconsistent results. All studies covered a short period of time. Few side effects of valeriana were reported. Only two studies compared valeriana to established hypnotics., Interpretation: We conclude that valeriana may have some hypnotic effect. Long-term studies are clearly lacking, as well as studies comparing valeriana to well-established drug treatments for insomnia.

Background: Information on treatment facilities for legal drug dependence in Norway is not readily available., Material and Method: In 2001 a questionnaire on the treatment of legal drug dependence was mailed to 254 psychiatric and substance abuse inpatient and outpatient clinics., Results: Of the 189 respondents, 25 psychiatric and 37 substance abuse clinics had treated patients with legal drug dependence in 1999-2000. Several clinics had insufficient registration systems. 34 out of 39 outpatient and 14 out of 35 inpatient clinics used gradual, as opposed to immediate, discontinuation of drug use. Abstention from all addictive drugs was a more common treatment goal for the substance abuse clinics than for the psychiatric clinics. Use of other drugs in the treatment was inconsistent between the different clinics. Half of the clinics claimed to base their treatment on scientific evidence. Only nine of 60 clinics had made systematic evaluations of treatment efficiency., Interpretation: Institutional treatment for legal drug dependence in Norway in 1999-2000 was not well organised, and treatment ideologies and goals were diverse. We recommend one specialised clinic in this field in each of the five regional health administrations.

Background: Thalidomide was introduced as a non-toxic sleeping pill in 1957 and was prescribed in more than 20 countries. In 1961 the link between congenital limb defects and thalidomide use in pregnancy was proven, resulting in withdrawal of the drug., Material and Methods: On the basis of literature searches and personal experience we review the effects and use of thalidomide today., Results: In vitro, thalidomide has immunoregulatory properties. This has lead to the administration of thalidomide in many immunological diseases. In 1964 it was discovered that thalidomide was effective against erythema nodosum leprosum. Thalidomide also has effect on aphthous stomatitis and Behçet's disease. The effect is more uncertain in graft-versus-host-disease, rheumatoid arthritis and Crohn's disease. Thalidomide reduces angiogenesis in experimental animals, and this has led to several studies of thalidomide as a possible anticancer drug. Advanced or resistant multiple myeloma may be a new target for thalidomide; at least 30% of these patients obtain response during treatment. Results indicate that patients with breast cancer and glioma do not benefit from treatment with thalidomide., Interpretation: Thalidomide has proven to be effective in the treatment of erythema nodosum leprosum and aphthous stomatitis. It is also effective in advanced multiple myeloma, but not in other cancers.

Norwegian County Medical Officers monitor unsatisfactory prescription practices in relation to addictive drugs. In this context, our team has tried to reach out to colleagues with preventive guidance. Our aim was to build communications skills by promoting systematic reflection on the importance of our own attitudes and behaviour in our work as physicians. In collaboration with the Vestfold Branch of the Norwegian Medical Association and the Vestfold Addiction Clinic, the Vestfold County Medical Officer set up preventive guidance tutorials for a closed group. The County Medical Officer specifically invited 20 physicians; invitations were also sent to all other members of the Medical Association in the county. The tutorials were given in 1997-98, with a voluntary attendance of 15 physicians. An evaluation form was sent to participants two months after completion. The tutorials received a positive evaluation. The results suggest that the guidance on the whole was considered useful. Of those specifically invited, 10% (2) attended. The tutorials were meant as a practical step to helping doctors reflect more systematically on their own style of communication and understanding of pain behaviour. There is a common interest in expanding the conventional biomedical model of understanding of chronic non-malignant pain conditions, a model in which prescribing addictive drugs is quite controversial.

In 1994 zopiclone (Imovane), a cyclopyrrolon, was introduced in Norway as a new kind of hypnotic. In 1996 zopiclone had a 26% share of the hypnotic market. This review of relevant literature has revealed a lack of documentation on the adverse effects of zopiclone. The similarities between zopiclone and benzodiazepine hypnotics are more striking than the differences. The bulk of comparative research has been carried out with triazolam, a drug taken off the Norwegian market in 1991. With zopiclone there is less inhibition of psychomotor function the day after intake than with flunitrazepam. Zopiclone causes less subjective "hangover" than nitrazepam, but there is a similar inhibition of psychomotor function the day after intake, and in some cases greater addictive potential.

Many of the procedures carried out on paediatric patients are both painful and frightening to the child. To increase the child's comfort and to promote good working conditions, it may be necessary and advisable to sedate the child. In this study, 125 children (63 boys and 62 girls) were sedated with midazolam. For most children (n = 110) the medication was administered as nose drops. The reasons for sedation were echocardiography (n = 51), venous or lumbar punction (n = 53) and computer tomography scan (n = 21). The overall success rate was 78%. Minor complications were registered in four children. Two children vomited and one child developed a facial rash. One child had prolonged sedation, but this did not affect its respiration. We conclude that midazolam given as nose drops is a safe and convenient way of sedating paediatric patients.

Because of frequent use of hypnotics to treat insomnia in the population in general and in institutions especially, an alternative programme of treatment has been developed at the psychiatric hospital, Modum Bads Nervesanatorium. The programme includes different components and levels of treatment, wherein use of hypnotics is the last choice. The main focus is on sleep hygiene, which consists mainly of working on the patients' own attitude towards and experience of sleep problems. The pre-requisite for running such a programme is a systematic approach to these attitudes among the staff, and the prescribing patterns by physicians.