Does improvement in the benzodiazepine prescribing indicator reflect more appropriate prescribing of hypnotics?

The benzodiazepine prescribing indicator included in the NHS performance indicator set for health authorities (HAs) has shown decreased prescribing of benzodiazepines, ie, improved performance National data show that use of hypnotics has not decreased due to increased prescribing of newer non‐benzodiazepine hypnotics Analysis of change in prescribing across HAs for October to December 1999 and 2001 shows that use of temazepam and nitrazepam has decreased in each HA but only one HA has shown a decrease in prescribing of zopiclone, zolpidem and zaleplon In 10 HAs overall prescribing of these 5 hypnotics has increased suggesting that prescribing of these drugs is not well managed in these HAs A high score on the health deprivation and disability index is associated with a higher prescribing rate for hypnotics therefore tackling the root causes of health inequalities may eventually lead to less demand for hypnotics     

Patients,prescribing, and benzodiazepines

Summary In order to establish the current status of benzodiazepine prescribing and also to assess patients' attitudes towards the use of these drugs, we interviewed 450 consecutive patients in 16 community pharmacies about their use of benzodiazepines.Prescribing rates increased ten-fold from the age of 20 to 70 years and were higher in women than in men. The average dose used in the elderly seemed excessive and the choice of hypnotic often inappropriate.The median duration of benzodiazepine use was 2.5 years (range 0–25) and 66% of the patients had been taking benzodiazepines for one year or more.Most of the patients (97%) found the drugs effective in the treatment of anxiety or insomnia. Twenty-two percent took a lower dose than prescribed and 7.5% a higher dose.These data suggest that benzodiazepines are prescribed for excessively long periods and that greater caution is needed in prescribing benzodiazepines for older patients.     

Gender and use of hypnotics or sedatives in old age: a nationwide register-based study

Objective To investigate whether gender is associated with use of hypnotics or sedatives and with different types of hypnotics or sedatives in older people after adjustment for age, socioeconomic status (i.e., education) and co-morbidity (i.e., number of other drugs). Setting Sweden Method We conducted a register-based analysis of data on gender, age, dispensed drugs, and education from people aged 75-89 years registered in the Swedish Prescribed Drug Register between July and October 2005 (n = 645,429). Main outcome measure The hypnotic or sedative drug classes were benzodiazepines, benzodiazepine related drugs (i.e., Z-drugs) and other types of hypnotics or sedatives. The individual hypnotics or sedatives were nitrazepam, flunitrazepam, triazolam, zopiclone, zolpidem, clomethiazole and propiomazine. Results In the total study population, 27.1% of the women and 18.1% of the men were dispensed at least one hypnotic or sedative drug. The logistic regression analyses of those who used hypnotics or sedatives (n = 151,700) revealed that women were more likely than men to use benzodiazepines (adjusted OR = 1.11; 95% CI 1.07?C1.14) and benzodiazepine related drugs (adjusted OR = 1.14; 95% CI 1.12?C1.17), whereas men were more likely to use other types of hypnotics or sedatives (adjusted OR = 0.69; 95% CI 0.67?C0.71). Among the individual hypnotics or sedatives, the strongest associations with gender was found for nitrazepam (adjusted OR = 1.19; 95% CI 1.14?C1.25 for women compared with men), zolpidem (adjusted OR = 1.18; 95% CI 1.16?C1.21), clomethiazole (adjusted OR = 0.48; 95% CI 0.46?C0.51) and propiomazine (adjusted OR = 0.77; 95% CI 0.75?C0.79). Conclusion Use of hypnotics or sedatives in old age seems to be related to female gender. Also, among elderly users of hypnotics or sedatives, women appear to be more likely to use benzodiazepines and benzodiazepine related drugs than men. The explanation to these gender differences merits further investigation.     

Assessing the effects of an intervention by a pharmacist on prescribing and administration of hypnotics in nursing homes

Introduction: We have previously reported sub optimal use of hypnotics in geriatric institutions. In the present study we examined the intervention by a pharmacist on the prescribing and administration of hypnotics in nursing homes. Thus a follow up study was performed in 5 nursing homes included in the previous study.Method: In the period between the two surveys the pharmacist provided drug information on the rational use of hypnotics, both written and verbal, to the staff of the institutions. Data on the administration of hypnotics was obtained from the Cardex system in the institutions. Data were compared to a control group in other nursing homes, where no intervention was carried out.Results: Although the population was older in 2000 than in 1995, the proportion of patients using hypnotics (24%) was similar. Use of benzodiazepines was reduced from 81% to 40%, use of long acting benzodiazepines was reduced from 62% to 22%, and use of shortacting hypnotics (zopiclone, zolpidem) increased from 9% to 53%. Furthermore, hypnotics administered before 9 p.m. were reduced from 40% to 14%, and the time of administration showed less variation than before. In the control population we also observed the use of short acting hypnotics in favour of benzodiazepines, similar to the results in the 5 institutions. However, in this population a significantly higher proportion of patients used hypnotics, used more than 1 hypnotic and the hypnotics were administered earlier in the evening.Conclusion: The results demonstrate an important effect of written and verbal drug information provided by a pharmacist to improve the prescribing and administration on the use of hypnotics in nursing homes.     

Effects of zopiclone and temazepam on sleep,behaviour and mood during the day

Summary Over a 3 week period the hypnotic effect of zopiclone 7.5 mg, temazepam 20 mg and placebo was investigated in a double-blind, cross-over study in 60 out-patients.The hypnotic effect, subdivided in the parameters sleep quality, latency of sleep onset and status after awaking, was scored daily by the patient after arising. The results showed that zopiclone 7.5 mg and temazepam 20 mg were almost equally effective. In sleep quality and latency of sleep onset, there appeared to be a non-significant trend favouring zopiclone. Both hypnotics differ significantly from placebo.Mood and behaviour during the day, as well as somatic symptoms and side-effects, were also scored daily and showed no significant differences between the treatments.The third week, which was a placebo week for all patients, showed a gradual improvement in sleep quality. It supports the case for not prescribing hypnotics for more than 2 weeks.     

Metabolism of benzodiazepine and non-benzodiazepine anxiolytic-hypnotic drugs: an analytical point of view

A review with 132 references. Several kinds of anxiolytic and hypnotic drugs are currently available on the market. Although BZDs are surely the most frequently prescribed among them, several chemically unrelated compounds have been commercialised, which can provide similar or even higher efficacy and tolerability. These drugs can prove useful for patients who are non-responder or intolerant to benzodiazepine treatment, thus giving broader therapeutic options to the clinician. The most important studies on the metabolic characteristics of several non-benzodiazepine anxiolytics and hypnotics are reported and briefly discussed in this review; moreover, the analytical methods related to these studies are also described and commented upon and their characteristics are highlighted. Finally, an update is included on recent (2007-2010) metabolism and pharmacokinetic studies on benzodiazepines. A monograph is included for each of the following drugs: zolpidem, zaleplon, zopiclone, ramelteon, buspirone and tandospirone; updates are included for the following benzodiazepines: alprazolam, bromazepam, diazepam, flunitrazepam, lorazepam, midazolam, oxazepam and triazolam.     

Correlates of Dependence and Beliefs About the Use of Hypnotics Among Zolpidem and Zopiclone Users

Background: Zolpidem and zopiclone are the two most commonly prescribed Z-drugs approved to treat insomnia. Objectives: To examine the demographic and clinical correlates of dependence and beliefs about hypnotic use among long-term zolpidem and zopiclone users in psychiatric treatment for insomnia. Methods: A total of 392 psychiatric outpatients who received zolpidem or zopiclone treatment for at least 3 months for insomnia were studied. Participants’ severity of hypnotic dependence and beliefs about the use of hypnotics to treat sleep problems were assessed. The correlation of dependence and beliefs about zolpidem and zopiclone treatment with demographic characteristics, hypnotic-using behaviors, co-use of addictive substances, and depressive symptoms were analyzed using multiple regression analysis models. Results: Zolpidem users reported more severe dependence and a lower level of necessity regarding the use of hypnotics than zopiclone users did. High equivalent doses of hypnotics and long duration of use were significantly associated with severe dependence and a low level of necessity. Severe depressive symptoms were signiciantly associated with severe dependence, a low level of necessity, and a low level of concern. Educational level was also associated with the levels of concern and necessity. Conclusions/Importance: There were differences in the level of dependence and belief about hypnotic use between zolpidem and zopiclone users. The correlates of dependence and belief identified in this study can serve as the basis for prevention and intervention programs.     

Are there gender differences in the prescribing of hypnotic medications for insomnia?

Gender differences in the prescribing patterns of general classes of medications for insomnia were examined. The classes of medications included: zopiclone, antidepressants, benzodiazepines, antihistamines and no medication. The sample comprised a sub-set of respondents from 2620 questionnaires of the Canadian Multicentre Sleep Database. Respondents for this database were contacted through physicians, announcements in the media and local pharmacies. The results indicated that gender alone was not associated with differential prescribing for insomnia, nor was gender associated with patterns of medication use such as frequency of taking medication, length of use, taking more or less medication than prescribed or attempts to stop taking medication. Demographic factors were included in the analysis and age and marital status were associated with different prescribing patterns for men and women with insomnia. It is possible that physicians refer to stereotypic expectations when prescribing hypnotics.     

Benzodiazepine drugs in general medical patients.

Data from a hospital-based drug surveillance programme were used to determine how often benzodiazepine drugs were used in general medical wards. Benzodiazepines were the drugs most commonly used as hypnotics and were given to 32% of these patients. Concomitant use of more than one benzodiazepine drug or of benzodiazepines with other psychoactive drugs was common and often irrational. A series of double-blind patient-preference studies comparing various benzodiazepines and a benzodiazepine with an antihistamine showed that for short-term hypnotic effect there were no differences between three common benzodiazepines but elderly patients preferred benzodiazepines to the antihistamine, which produced more undesired effects. These results suggest that currently diazepam is the hypnotic of choice for medical ward inpatients.     

Zopiclone. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy as an hypnotic

Zopiclone is the first of the cyclopyrrolones, a new class of psychotherapeutic agents possessing a pharmacological profile of high efficacy and low toxicity similar to that of the benzodiazepines. Binding is thought to occur to the benzodiazepine receptor complex, or to a site closely linked to this complex. Although zopiclone exhibits anticonvulsant, muscle relaxant and anxiolytic properties in animals, it finds better use as an hypnotic because of marked sedating effects. In clinical trials, zopiclone (usually 7.5 mg) improved sleep in chronic insomniacs similarly to nitrazepam 5 mg, flurazepam 15 to 30 mg, triazolam 0.5 mg and temazepam 20 mg, but in a single study was slightly less effective than flunitrazepam 2 mg in some evaluation criteria. Sleep induction before surgical procedures in hospitalised patients is satisfactory with zopiclone, but when the drugs are administered a few hours before surgery, diazepam appears to be more effective in alleviating preoperative anxiety. Minimal impairment of psychomotor skills and mental acuity occurs in the morning after a bedtime dose of zopiclone, which has a short half-life of about 5 hours and no long acting metabolites. No serious side effects have been reported in the relatively small number of patients studied to date; the development of 'bitter taste' does not deter patients from continuing therapy. Thus, with its short duration of action zopiclone is a useful alternative to other hypnotics, especially in patients intolerant of residual effects the morning after taking an hypnotic.