Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers

General practitioners' preferences for managing insomnia and opportunities for reducing hypnotic prescribing

RATIONALE, AIMS AND OBJECTIVES

Insomnia and sleep problems are common with many sufferers seeking medical help from general practitioners (GPs) whose clinical response is limited, often involving prescription of hypnotic drugs. The case for improving the quality of care for patients with insomnia is compelling but there is little evidence about how better care could be achieved in a primary care setting. The aim of this study was to investigate GPs' management preferences for sleep problems and their awareness and perception of opportunities for improving care as well as reducing the use of benzodiazepines and Z drugs.

METHODS

Cross-sectional survey of GPs using a self-administered postal questionnaire in 2005 to all GPs in West Lincolnshire Primary Care Trust Lincolnshire, UK.

RESULTS

A total of 84 of 107 (78.5%) questionnaires sent to GP principals were returned after one reminder. Respondents favoured Z drugs over benzodiazepines for the majority of indications. Respondent attitudes to benzodiazepines and Z drugs were generally negative whereas they were positive towards initiatives to reduce hypnotic prescribing through personal guidance, awareness-raising strategies and organizational interventions.

CONCLUSIONS

GPs were negative in attitude towards hypnotics and positive towards reducing prescribing for sleep problems. They need to develop resources and better strategies for assessment and non-pharmacological management of patients presenting with insomnia for the first time as well as those on long-term hypnotics. The feasibility and effectiveness of psychosocial interventions tailored to patient and service needs in primary care setting should be evaluated systematically seeking to understand potential clinical benefits as well as potential undesirable effects of service changes.

Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care

BACKGROUND

Little is known about patients' perceptions of newer hypnotics.

AIM

To investigate use, experience, and perceptions of Z drug and benzodiazepine hypnotics in the community.

DESIGN OF STUDY

Cross-sectional survey of general practice patients who had received at least one prescription for a Z drug or benzodiazepine in the previous 6 months.

SETTING

Lincolnshire, UK.

METHOD

Self-administered postal questionnaire.

RESULTS

Of 1600 surveys posted, 935 (58.4%) responses were received, of which 705 (75.4%) were from patients taking drugs for insomnia. Of those 705 patients, 87.9% (n = 620) were first prescribed a hypnotic by their GP, and 94.9% (n = 669) had taken a sleeping tablet for 4 weeks or more. At least one side effect was reported in 41.8% (n = 295); 18.6% wished to come off hypnotic medication; and 48.5% had tried to stop treatment. Patients on Z drugs were more likely to express a wish to stop (22.7% versus 12.3%; odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13 to 2.49), or to have attempted to come off medication, than those on benzodiazepines (52.4% versus 41.0%; OR = 1.54, 95% CI = 1.12 to 2.12). The two groups did not differ significantly in respect of benefits or adverse effects.

CONCLUSION

There were no significant differences in patients' perceptions of efficacy or side-effects reported by those on Z drugs compared to patients taking benzodiazepines. Side-effects were commonly reported, which may have contributed to a high proportion of responders, particularly patients on Z drugs who were wishing to stop, or who had previously tried to stop taking this medication. Reported prescribing practices were often at variance with the licence for short-term use.

[Prescription patterns and quality of information provided for consumers of benzodiazepines]

The long-time benzodiazepine use by a considerable part of the population and its adverse consequences such as somatic and cognitive side effects, interactions with other drugs and alcohol and its possible impairment of quality of life has provoked a critical discussion about the practice of prescribing benzodiazepine and the information provided by physicians. We therefore investigated these issues in admitted patients of a general hospital. All patients having been admitted to the department of Internal Medicine and taking benzodiazepine were asked by means of a semi-structured interview, which was repeated after 1 year. In 90% of later benzodiazepine discontinuers and in almost 50% of benzodiazepine continuers, tranquilisers were first prescribed during hospital admission. Only 2% of all patients estimated the information provided by the prescribing physicians as satisfying and about 2/3 reported that they did not get any information at all. 66% of all patients were informed about dependency risks. This information was mainly provided by pharmacies, friends and patient information leaflets; only about 20% of all patients were informed by the prescribing physician. Guidelines for tranquiliser prescription only seem to have a poor impact on the clinical practice. The education of physicians about the risks of low-dose dependencies and especially about complementary therapy methods needs to be improved.

Small platform stress attenuates the anxiogenic effect of diazepam withdrawal in the plus-maze test

The effect of stress on the behavioural changes caused by diazepam withdrawal was studied in mice. Diazepam (2.5 mg/kg) or vehicle was injected intraperitoneally twice a day for 2 weeks. When the last vehicle or diazepam injection had been administered to the mice, 12 h later, the mice were subjected to small platform stress exposure or left in their home cages. Small platform stress was induced by placing mice on small platforms (3.5 cm diameter) surrounded by water for 24 h. This experimental model contains several factors of stress like rapid eye movement (REM) sleep deprivation, isolation, immobilization and falling into the water. The plus-maze test was carried out with stressed mice as well as with mice not subjected to stress. Small platform stress induced an anxiolytic effect and diazepam withdrawal--an anxiogenic effect in the plus-maze test. Small platform stress also attenuated the anxiogenic effect of diazepam withdrawal. On the basis of this data it was proposed that small platform stress counteracts the anxiogenic effect of diazepam withdrawal in the plus-maze test. It was also proposed that the effect of stress on the signs of benzodiazepine withdrawal depends on the characteristics and duration of stress.

Physician responses to an educational intervention on improving their long-term prescribing of sedatives

The current study examined response forms returned by physicians in response to a Medicaid retrospective therapeutic intervention on the long-term use of sedatives. The educational intervention was designed to notify physicians about their patients' long-term use of sedatives and suggest that they reevaluate the patient's need for sedative hypnotic medication and decrease or discontinue prescribing the medication and/or suggest non-pharmacological alternatives if deemed appropriate. Forty-seven percent of physicians responded to the educational intervention. Nineteen percent of responding physicians planned to change the patient's medication in some way. The most common planned change was to decrease the dose. Physicians also stated that they would recommend one or more non-pharmacological alternatives to 17% of patients. Thirty-eight percent of physicians planned to monitor and/or counsel the patient. Over 40% of physicians reported planning no action after receiving the intervention. Twenty-six percent of physicians planned no action because of patient demand for the sedatives. The study concludes that physicians need to be better trained on how to: (1) discuss non-pharmacological treatments with patients and (2) deal with and respond to patients who demand controlled substances.

Abuse liability of flunitrazepam

Flunitrazepam is among the most frequently prescribed hypnotics in many countries. Although it was never marketed in the United States, flunitrazepam, in recent years, has been smuggled into the country, and reports of abuse--including alleged use of the drug to facilitate "date rape"--have attracted a great deal of scrutiny. It has been suggested that flunitrazepam may have greater liability for abuse than other benzodiazepines; such suggestions are supported by surveys of opioid abusers, many of whom report a distinct preference for flunitrazepam over other benzodiazepines. Experimental studies of animals and normal human subjects indicate that, although flunitrazepam has high efficacy and is very potent, it is pharmacologically similar to most other benzodiazepines. Although the studies are limited in number and scope, the data show no apparent differences between flunitrazepam and other benzodiazepines in ability to produce drug-taking or drug-seeking behavior, in capacity to produce physiologic dependence, nor in the characteristics of withdrawal after administration of an antagonist or discontinuation of treatment. Similar to other benzodiazepines, flunitrazepam produces dose-dependent effects on psychomotor performance and recall. Flunitrazepam does not seem to be involved in medical emergencies more often than other benzodiazepines, and there is no indication that flunitrazepam is more toxic than other benzodiazepines when taken in overdose by drug abusers or other individuals. Survey research among typical patient populations suggests that flunitrazepam is characteristic of benzodiazepines in that it is used appropriately and conservatively, with low liability for abuse. Thus the reported preference for flunitrazepam among opioid abusers seems to be the only way in which flunitrazepam is distinguished from other benzodiazepines; it is unclear what characteristics of the drug may be responsible for this reported preference. The evidence considered in this review indicates that abuse of flunitrazepam in this special population is not associated with any distinctive threats to the health of the general public.

Sleep quality and the use of benzodiazepine hypnotics in general practice

The aim of the study was to determine the usage patterns of benzodiazepine hypnotics, the use of other ways of improving sleep and general sleep characteristics in patients prescribed these drugs on a regular basis and in a control group of age- and sex-matched patients not receiving hypnotics. Patients receiving regular benzodiazepine hypnotic prescriptions and a control group matched for age and sex were identified from a general practice computer. They were interviewed in their own homes about their habits relating to sleep, hypnotic use and attitudes to sleep and hypnotics. None of the recommended methods of improving sleep differed significantly in frequency between the two groups or had an effect on sleep parameters. Only daytime napping was found to be slightly more frequent in hypnotic users, but had no apparent effect on self-estimates of sleep duration or latency. The hypnotic users claimed a longer sleep latency and a shorter sleep duration than non-users. More patients who took hypnotics also perceived them to be beneficial and more convenient than other ways of promoting sleep. The recommendation of sleep-promoting methods such as caffeine and alcohol avoidance and regular exercise may not be helpful in patients attempting to avoid hypnotics, as many patients already claim to use such methods.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

Are patterns of benzodiazepine use predictable? A follow-up study of benzodiazepine users

A sample of 171 patients taking benzodiazepines (BZDs) who had been investigated in 1988 was followed up in 1991. From 140 patients who were still alive and willing to participate, 25% had stopped BZDs after an average duration of intake of 34 months. Of the 105 persons still taking a BZD, 37% were taking the same dose, 26% had reduced the dose and 37% had increased it. Characteristics of BZD long-term users and patients potentially at risk for abuse and/or dependence that were established from the 1988 data were reexamined: patients with continued BZD use more often suffered from somatic illness which often had deteriorated, they had a longer duration of intake and used higher daily doses. In most cases the indication was insomnia. Patients with a clinically relevant dose increase were more often males, frequently found to be dependent on alcohol and/or illegal drugs.

The effects of alcohol and benzodiazepines on the severity of ski accidents

Urine samples from 402 victims of ski accidents were analyzed for the presence of benzodiazepines (BZD) and alcohol. Eighty-one (20%) samples were positive for alcohol; BZD were detected in 34 (8.5%) cases. Ten of the samples (2.5%) were found to be positive for both alcohol and BZD. Subjects who were positive for either alcohol or BZD or both were older than the other persons examined. The prevalence of alcohol was significantly higher among male accident victims. BZD intake could be demonstrated to have a significant influence on the severity of injuries. Besides an increased awareness of the need for skier education regarding drug use, heightened attention of medical caregivers is warranted to inform their patients about potential accident hazards in sport activities when BZD are prescribed.