Sedative hypnotic use in Alberta

Zopiclone-Induced Methemoglobinemia: A Case Report Highlighting How the Treatment Differs in Patients on Serotonergic Medication

Zopiclone is a sedative-hypnotic that is increasingly being used for insomnia, especially among patients with depression. The side effects of zopiclone include nausea, vomiting, headache, giddiness, sedation, altered mental status, and coma. Here, we describe a rare case of a patient with underlying depression who overdosed on zopiclone, resulting in a presentation of drowsiness and dyspnea. A diagnosis of methemoglobinemia was made only through astute observation of the presence of a saturation gap, poor oxygen saturation despite high flow oxygen supplementation, and the arterial blood gas sample appearing chocolate brown in color. Treatment of such patients usually includes the gold standard of methylene blue. However, in our case, there was a risk of serotonin syndrome as the patient was on a serotonergic antidepressant prior. As such, an alternative treatment with ascorbic acid was utilized instead. Methemoglobinemia, while uncommon, should always be suspected in patients who present with zopiclone overdose as it can be life-threatening and is easily treatable.

Zopiclone to treat insomnia in older adults: A systematic review

Considering the global increase in use of Z-drugs to treat insomnia, the study objective was to conduct a systematic review on the efficacy and safety of zopiclone to treat sleep disorders in older adults compared to other sedative-hypnotics, to placebo or to non-pharmacological interventions. The literature search for original reports - clinical trials, cohort studies and cross-sectional, observational investigations - was done in eleven databases and web search engines followed PRISMA guidelines, and methodological quality was assessed using the Risk of Bias tool in the Cochrane Reviewers' Handbook. The search resulted in 12 randomized, placebo-controlled clinical trials along with 2 open studies and 2 observational reports. Overall, the studies suggest that zopiclone is effective to treat insomnia by reducing sleep latency, nocturnal awakenings and wake time after sleep onset while increasing total sleep time, with probable effects on sleep architecture. Zopiclone was found to be fairly tolerated, to induce a low rate of adverse events with non-severe impact on psychomotor or cognitive performance and to produce no major harm to the overall well-being and daily living abilities. However, the quality of most studies was classified as low or unclear. Though the studies available support benefits from zopiclone use, there is still a need for further evidence on long-term effects, tolerability and safety in the treatment of older adults by means of high-quality trials.

Characterisation of concurrent use of prescription opioids and benzodiazepine/Z-drugs in Alberta, Canada: a population-based study

OBJECTIVE

The objective of this study is to characterise concurrent use of benzodiazepine receptor modulators and opioids among prescription opioid users in Alberta in 2017.

DESIGN

A population based retrospective study.

SETTING

Alberta, Canada, in the year 2017.

PARTICIPANTS

All individuals in Alberta, Canada, with at least one dispensation record from a community pharmacy for an opioid in the year 2017.

EXPOSURE

Concurrent use of a benzodiazepine receptor modulator and opioid, defined as overlap of supply for both drugs for at least 1 day.

MAIN OUTCOME MEASURES

Prevalence of concurrency was estimated among subgroups of patient characteristics that were considered clinically relevant or associated with inappropriate medication use.

RESULTS

Among the 547 709 Albertans who were dispensed opioid prescriptions in 2017, 132 156 (24%) also received prescriptions for benzodiazepine receptor modulators. There were 96 581 (17.6%) prescription opioid users who concurrently used benzodiazepine receptor modulators with an average of 98 days (SD=114, 95% CI 97 to 99) of total cumulative concurrency and a median of 37 days (IQR 10 to 171). The average longest duration of consecutive days of concurrency was 45 (SD=60, 95% CI 44.6 to 45.4) with a median of 24 days (IQR 8 to 59). Concurrency was more prevalent in females, patients using an average daily oral morphine equivalent >90 mg, opioid dependence therapy patients, chronic opioid users, patients utilising a high number of unique providers, lower median household incomes and those older than 65 (p value<0.001 for all comparisons).

CONCLUSIONS

Concurrent prescribing of opioids and benzodiazepine receptor modulators is common in Alberta despite the ongoing guidance of many clinical resources. Older patients, those taking higher doses of opioids, and for longer durations may be at particular risk of adverse outcomes and may be worthy of closer follow-up for assessment for dose tapering or discontinuations. As well, those with higher healthcare utilisation (seeking multiple providers) should also be closely monitored. Continued surveillance of concurrent use of these medications is warranted to ensure that safe drug use recommendations are being followed by health providers.

Major Depression in Canada: What Has Changed over the Past 10 Years?

OBJECTIVE

Major depressive episodes (MDE) make an important contribution to disease burden in Canada. The epidemiology of MDE in the national population has been examined in 2 mental health surveys, one conducted in 2002 and the other in 2012. Our objective was to compare selected variables from the 2 surveys to determine whether changes have occurred in the prevalence, treatment, and impact of MDE.

METHOD

The World Health Organization World Mental Health Composite International Diagnostic Interview was used in both surveys and the MDE module (which was not modified) was scored using the same algorithm. Some variables assessing impact and management of MDE were also identical in the 2 surveys. The analysis was based on frequency estimates and associated 95% confidence intervals.

RESULTS

The annual prevalence of MDE was 4.7% (95% CI 4.3% to 5.1%) in 2012, nearly identical to 4.8% (95% CI 4.5% to 5.1%) in 2002. Receipt of potentially adequate treatment (defined as taking an antidepressant or 6 or more visits to a health professional for mental health reasons) increased from 41.3% in 2002 to 52.2% in 2012, mostly due to an increase in respondents reporting 6 or more visits. Use of second generation antipsychotics also increased. There was no evidence of diminishing prevalence or impact (as assessed by symptoms of distress).

CONCLUSIONS

There appears to have been an increase in receipt of treatment for people with MDE and a changing pattern of management. However, it was not possible to confirm that the impact of MDE is diminishing as a result.

Zopiclone's residual effects on actual driving performance in a standardized test: a pooled analysis of age and sex effects in 4 placebo-controlled studies

BACKGROUND

In many European countries, Canada, and Japan, the nonbenzodiazepine zopiclone is now among the most frequently prescribed hypnotic drugs. This finding can be explained by the growing view among physicians that zopiclone is more effective and safer than conventional benzodiazepines. However, in 4 studies using similar procedures, it has been shown that zopiclone 7.5 mg causes moderate to severe impairment in driving performance.

OBJECTIVE

The goal of the present article was to review these studies and analyze the pooled data to determine whether the severity of effects is modified by the sex and age of the subjects.

METHODS

The driving data of the placebo and zopiclone 7.5 mg evening treatment periods from a total of 4 studies conducted at Maastricht University were included in this pooled analysis. All studies were conducted according to balanced double-blind, crossover designs. The effects on driving were always measured the next morning, between 10 and 11 hours after administration, by using a standardized highway driving test. A total of 101 healthy volunteers of both sexes in equal proportions (with no reports of insomnia) participated. Subjects comprised young volunteers (age range, 21-45 years) in 3 studies and older volunteers (age range, 55-75 years) in the fourth study.

RESULTS

Results show that zopiclone 7.5 mg has significant and clinically relevant performance-impairing effects on driving in the morning, until 11 hours after bedtime ingestion. The effects did not differ between male and female subjects and did not increase with age, at least until 75 years. The effects of zopiclone 7.5 mg are comparable to the effects of a mean blood alcohol concentration between 0.5 and 0.8 mg/mL, which has been associated with a 2- to 3-fold increase in the risk of becoming involved in a traffic accident.

CONCLUSIONS

We concluded that patients using an evening dose of zopiclone 7.5 mg should avoid activity in skilled work and participation in traffic the morning after intake. General practitioners' beliefs regarding the beneficial safety profile of zopiclone may need adjustment, and patients using zopiclone 7.5 mg should be warned accordingly. There is no need to differentiate warnings about zopiclone's residual impairing effects depending on the sex of the patient.

The utilization of antidepressants and benzodiazepines among people with major depression in Canada

OBJECTIVE

Although clinical guidelines recommend monotherapy with antidepressants (ADs) for major depression, polypharmacy with benzodiazepines (BDZs) remains an issue. Risks associated with such treatments include tolerance and dependence, among others. We assessed the prevalence and determinants of AD and BDZ utilization among Canadians who experienced a major depressive episode (MDE) in the previous 12 months, and determined the association of seeing a psychiatrist on the utilization of ADs and BDZs.

METHOD

Data were drawn from the 2002 Canadian Community Health Survey: Health and Well-Being, a nationally representative sample of Canadians aged 15 years and older. Descriptive statistics quantified utilization, while logistic regression identified factors associated with utilization, such as sociodemographic characteristics or type of physician seen. Sampling weights and bootstrap variance estimations were used for all analysis.

RESULTS

The overall prevalence of AD and BDZ utilization was 49.3% of respondents who experienced an MDE in the past 12 months and reported AD use. Key determinants of utilization were younger age and unemployment in the past week (OR 2.6; P < 0.001). Being seen by a psychiatrist increased utilization (OR 2.5; P < 0.001), possibly because psychiatrists were seeing patients with severe depression.

CONCLUSION

A large proportion of people with past-year MDEs utilized ADs and BDZs. It is unclear how much of this is appropriate given that evidence-based clinical guidelines recommend monotherapy with ADs in the treatment of major depression.

Psychomotor performance after intake of zopiclone compared with intake of ethanol: a randomized, controlled, double-blinded trial

The sleep medicine zopiclone (eszopiclone) is commonly used in most Western countries. The focus on legislation for possible traffic-impairing nonalcohol drugs have caused a need for comparing traffic relevant behavior after intake of commonly used psychoactive drugs to blood alcohol concentrations (BACs). We aimed to compare psychomotor effects at 3 levels of behavior at different blood zopiclone concentrations to effects seen at different BACs. We performed a randomized double-blinded trial on 16 healthy volunteers who received either 10 or 5 mg zopiclone, 50 g ethanol or placebo in a crossover design. The volunteers performed computerized tests at baseline, 1, 3.5, and 6.5 hours after intake, accompanied by blood sampling. Impairment was found at all 3 behavior levels. For zopiclone, impairment was most pronounced at behavior level 1 (automotive behavior); a mean blood zopiclone concentration at 39 μg/L achieved 1 hour after intake of 10 mg zopiclone was accompanied by more impairment than BAC 0.074 %. At behavior levels 2 (control behavior) and 3 (executive planning), the psychomotor impairment accompanying approximately 39 μg/L zopiclone seemed comparable to a BAC of approximately 0.074%. No test components were impaired at 6.5 hours after intake.

Zolpidem and zopiclone impair similarly monotonous driving performance after a single nighttime intake in aged subjects

RATIONALE

Although hypnotics are primarily used by older people, the residual effects the morning after a single nighttime intake of the two most commonly prescribed hypnotics, zolpidem (Zp) and zopiclone (Zc), on older middle-aged drivers have not been evaluated and compared.

METHODS

Sixteen healthy subjects, 55 to 65 years of age, participated in this double-blind, balanced, cross-over study. Zc (7.5 mg), Zp (10 mg) and flunitrazepam (Fln) (1 mg) or a placebo was administered at each subject's home at 11.00 pm. The next morning, at 9.00 am, the subjects had to drive in a simulated monotonous driving environment for 1 h. During each morning session, two blood samples were collected, and subjective feelings of alertness were completed three times.

RESULTS

In comparison to placebo, Zp and Zc equivalently and significantly impaired the standard deviation of lateral position, the standard deviation of speed and the number of road exits. Detectable blood concentrations were found with Zp in 11 subjects at 8.30 am and at 1.30 pm. The subjective alertness factor was significantly impaired with Zp.

CONCLUSIONS

This is the first study revealing residual effects of Zp on driving performance in ageing drivers which are similar to that of Zc. Studying the effects of medication in different age ranges appears useful to complete the studies on behavioural-pharmacological effects of medication. To reduce the incidence of driving accidents due to prescription drugs, patients should be warned at the time of treatment initiation that they should avoid driving.

Pharmacoepidemiology of benzodiazepine and sedative-hypnotic use in a Canadian general population cohort during 12 years of follow-up

OBJECTIVE

benzodiazepines (BDZs) and similar sedative-hypnotics (SSHs) can have both beneficial and adverse effects. Clinical practice guidelines indicate that the course of treatment should usually be brief (a few weeks), but patients often take these medications for longer periods of time. We hypothesized that treatment with antidepressants (ADs) would be associated with a shorter duration of SSHs use as mood and anxiety disorders may underlie the symptoms usually targeted by BDZ treatment.

METHOD

our study used data from a Canadian longitudinal general health study, the National Population Health Survey, which has collected data since 1994. Data are currently available to 2006. At each interview, all medications taken in the preceding 2 days are recorded. In our study, we used proportional hazard models to describe patterns of initiation and discontinuation of these medications in the general population.

RESULTS

at each interview, the frequency of BDZ-SSH use was 2% to 3%. About 1% of the population initiated use in each 2-year follow-up period. Contrary to expectation, taking ADs predicted initiation of BDZ-SSHs, but not discontinuation.

CONCLUSIONS

unexpectedly, respondents taking ADs had a higher frequency of new BDZ-SSH use. AD use may be a marker for depression severity or comorbidity, such that the observed results may be an artifact of confounding by these factors. Irrespective of etiology, initiation of AD treatment does not appear to negate the risk of long-term BDZ-SSH use.

Highway driving in the elderly the morning after bedtime use of hypnotics: a comparison between temazepam 20 mg, zopiclone 7.5 mg, and placebo

A major problem related to hypnotic drug use is residual sedation the morning after bedtime administration. This constitutes a particular safety hazard for patients who have to drive a car the next morning. Information on the severity of residual effects is mainly derived from studies conducted with young healthy volunteers. However, most users of hypnotics are older people who may be more sensitive to drug effects. The aim of this study was to evaluate the residual effects the morning after evening doses of temazepam 20 mg and zopiclone 7.5 mg on driving performance in healthy elderly drivers. Eighteen healthy elderly drivers (10 females and 8 males; mean age, 64.3 years) participated in a double-blind, 3-way crossover study. Treatments were single oral doses of temazepam 20 mg, zopiclone 7.5 mg, and placebo administered at bedtime. Subjects performed a standardized highway driving test between 10 and 11 hours after hypnotic intake. Before and after the driving test, cognitive performance was assessed. Driving performance did not differ between temazepam and placebo but was significantly impaired after zopiclone 7.5 mg (P < 0.002). The results of the laboratory tests were in line with the effects on driving of both hypnotics. Temazepam 20 mg is unlikely to impair driving 10 hours or more after bedtime administration in healthy elderly aged 75 years or younger. Zopiclone 7.5 mg moderately impairs driving in the elderly at least until 11 hours after administration. The magnitude of impairing effects in the elderly was comparable with those found previously in younger volunteers.

Impairment related to blood drug concentrations of zopiclone and zolpidem compared to alcohol in apprehended drivers

BACKGROUND

About 3-7% of the adult population receives prescribed hypnotics. The benzodiazepine-like hypnotics, zopiclone and zolpidem, are the most commonly prescribed and may cause traffic-relevant impairment similar to that found for benzodiazepines. We investigated the relationship between blood zopiclone and zolpidem concentrations and driving impairment, as assessed by the clinical test for impairment. We compared these groups of drivers to a group suspected of alcohol-related impairment.

METHODS

Blood samples from suspected impaired drivers during 2000-2007, screened for approximately 25 possible impairing drugs with only one single drug detected, were studied in relation to the assessment of impairment. The 79 zopiclone positive drivers, the 43 zolpidem positive drivers, and the 3480 alcohol positive drivers were divided into groups depending on blood drug concentrations.

RESULTS/DISCUSSION

The proportion of drivers judged as impaired tended to increase the higher the blood zopiclone concentrations. Such a positive relationship was not found for zolpidem. For alcohol the proportion of impaired drivers was significantly related to blood alcohol concentrations (BACs). There were few drivers with low zopiclone or zolpidem concentrations included, which may have obscured any positive significant relationship. The percentage of impaired drivers among drivers with blood zopiclone concentrations above 130 microg/l roughly corresponded to the percentage of impaired drivers among drivers with BACs higher than 0.1%.

Non-remission of depression in the general population as assessed by the HAMD-7 scale

Remission from the symptoms of depression is the optimal outcome for depression treatment. Many studies have assessed the frequency of treatment, but there are none that have estimated the frequency of treated remission in the general population. We addressed this issue in the population of Alberta using a brief Hamilton Depression Rating Scale (HAMD)-7 scale (recently validated against the HAMD-17 scale in a clinical setting) that has been proposed as a suitable indicator for remission in primary care. We used data from a survey conducted within the Alberta Depression Initiative in 2005 (n=3,345 adults), to produce a population-based estimate of the number of respondents taking antidepressant medication for depression. From this group we selected a subpopulation that did not screen positive when the MINI module for major depression was administered (i.e., who did not have an active episode). Non-remission in this subpopulation was assessed with a version of the HAMD-7 scale adapted for telephone administration by a nonclinician. Of the survey respondents, 189 reported taking antidepressant medication for depression. Of these, 115 were found not to have an active episode. However, 49.0% of this subpopulation was not in remission as evaluated by the HAMD-7. We estimate that 1.3% (95% confidence interval, 0.9-2.0%) of the population is in treated non-remission for depression. Our study indicates a substantial degree of non-remission from depression in individuals taking antidepressants in the general population. This suggests that, in addition to increasing the frequency of treatment, increasing the effectiveness of treatment can have an impact on population health.

Forgetfulness: a role in noncompliance with antidepressant treatment

OBJECTIVES

To determine the degree of noncompliance with antidepressant treatment in the Alberta population and to investigate the reasons for noncompliance.

METHOD

We used data from the Alberta Mental Health Survey, a telephone survey conducted in 2003 (n = 5323 adults), to produce population-based estimates of the frequency of noncompliance and the reported reasons for noncompliance.

RESULTS

Reported noncompliance was 41.7% (95% confidence interval [CI], 36.9% to 46.6%) for respondents taking 1, 2, or 3 antidepressants. Noncompliance for those taking 1 antidepressant was 42.0% (95%CI, 36.9% to 47.2%), whereas noncompliance for those taking 2 or 3 antidepressants was 39.4% (95%CI, 26.7% to 53.6%). Among respondents currently taking at least one antidepressant, 64.9% (95%CI, 57.4% to 71.7%) reported that forgetfulness was the most common reason for noncompliance. Of respondents taking 1 medication, 64.1% (95%CI, 56.0% to 71.4%) reported forgetfulness as did 71.3% (95%CI, 48.3% to 86.8%) of those taking 2 or 3 medications. Both the frequency of noncompliance and the reported reasons for noncompliance were independent of sex and age.

CONCLUSION

Our study replicates prior reports that indicate that noncompliance is common with antidepressant treatment. Forgetting to take medication is the most important reported reason for this noncompliance.