Appropriate use of zopiclone and benzodiazepines for the treatment of insomnia

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Audit Focus

Zopiclone and some benzodiazepines, such as temazepam and triazolam, are indicated for the short-term treatment of insomnia (i.e. four weeks or less). Long-term use of these medicines should be avoided where possible due to adverse effects and the potential for the development of dependence. The objective of the audit is to promote appropriate use of these medicines, particularly for those who are using these medicines long-term. Advice about the risks and adverse effects of these medicines and guidance on withdrawal should be given to all patients who receive prescriptions for these medicines.

Background

Zopiclone and some benzodiazepines although widely used, are not the preferred option for the long-term treatment of insomnia. Cognitive-behavioural approaches (e.g. “sleep hygiene”) are safer, have high levels of efficacy, are supported by a good evidence base, and achieve better outcomes in the long-term. In addition, these medicines have the potential for dependency and can cause a range of adverse effects, e.g. muscle weakness, vertigo, effects on cognition including an increased risk of dementia.

These effects can lead to adverse clinical outcomes, such as an increased risk of falls and increased risk of motor vehicle accidents. Elderly patients have reduced clearance of medicines and are likely to require a lower dose to minimise adverse effects. Discontinuing the use of zopiclone or a benzodiazepine may reverse some of these effects, e.g. improving motor performance, cognition and reducing the risk of dementia. Concomitant use of benzodiazepines or zopiclone with opioids or alcohol increases many risks, such as lack of judgement, sexual disinhibition, criminal activity and fatal overdose.

If other interventions to improve sleep have been unsuccessful, zopiclone or a short-acting benzodiazepine should be chosen and prescribed at the lowest effective dose for a short duration, ideally no more than four weeks, and preferably five to ten days. Prior to starting the medicine, patients should be given information about adverse effects and educated about the importance of not becoming reliant on these medicines. They should understand that they are for short-term use only. Many patients request further repeat prescriptions for hypnotics because they perceive that the rapid symptom relief that is often gained when using these medicines outweighs any adverse effects and risks. Prescriptions for zopiclone or benzodiazepines should therefore be written to take account of the risk of uncontrolled and escalating use, i.e. prescribed in limited quantities with regular review. However, there are no clear clinical guidelines regarding the appropriate medicine-free interval between short courses of hypnotics.

Prescribers should also be vigilant for drug-seeking behaviour, such as early requests for repeat prescriptions.

Patients who have been using these medicines long-term should be counselled against continuing use. Interventions to assist patients to withdraw include psychological support and counselling for underlying or concurrent problems they may have, regular follow-up appointments, e.g. fortnightly, patient information leaflets and reminder letters for patients regarding the risks of ongoing use.

For further information on benzodiazepine and zopiclone withdrawal strategies, see: www.bpac.org.nz/BPJ/2015/February/benzodiazepines.aspx

Note – Rapid withdrawal of benzodiazepines is associated with an increased risk of seizures, therefore patients who have been using these medicines long-term should be counselled against stopping their use abruptly.

Recommendation

Zopiclone and short-acting benzodiazepines should only be used on a short-term basis for the treatment of insomnia. Alternative non-pharmacological methods to improve sleep quality should have been discussed and ideally trialled. Patients should be advised of the adverse effects of these medicines and the potential for dependency. If patients have been using these medicines long-term, they should be counselled regarding the risks associated with their use and offered support and advice to assist with withdrawal. These discussions should be documented in clinical notes.

Audit plan

  • Select a random sample of patients who have recently been prescribed zopiclone, temazepam or triazolam (as these latter benzodiazepines are used principally for the treatment of insomnia).
  • Review the patient notes to establish if a conversation with the patient has been documented in which:
    • The patient has been advised of the potential for dependence with the use of these medicines
    • The patient has been counselled about other methods for the management of insomnia
    • If the medicines have been taken on an ongoing basis, the patient has been advised to discontinue use and supported to do so

Standards

Ideally 100% of patients prescribed zopiclone, temazepam or triazolam will have been counselled regarding the risks of using these medicines and the conversation documented in the notes. All patients who have been using these medicines for periods longer than recommended should have been provided with advice on withdrawal and of alternative methods to promote sleep. However, for the purposes of this audit a target of 90% of patients with documented conversations is suggested.

Data

Identifying patients

Search for patients who have been prescribed zopiclone, temazepam or triazolam in a recent month. Zopiclone is likely to be the most frequently prescribed hypnotic, but the audit should include temazepam and triazolam because they are the benzodiazepines used principally for the treatment of insomnia.

Sample size

The number of eligible patients will vary from practice to practice. Ideally sample size should be “all patients prescribed zopiclone, triazolam or temazepam in a selected month”. However, this may generate too large a sample size for some practices, and too small in others. If your practice has a large number of patients being prescribed these medicines, take the first 20 results returned from a search. If your practice has small numbers of patients prescribed these medicines, extend the search to include more than the previous month to allow the sample size to reach 20.

Review patient notes

Review the patient notes to establish if a conversation with the patient has been documented in which:

  • The patient has been advised of the potential for dependence with the use of these medicines
  • The patient has been counselled about other methods for the management of insomnia
  • If the medicines have been taken on an ongoing basis, the patient has been advised to discontinue use and supported to do so

Criteria for a positive result

In order to score a positive result in this audit, patients prescribed zopiclone, temazepam or triazolam for the treatment of insomnia should have documentation of a conversation regarding risks and adverse effects of these medicines, including dependence and alternative methods to manage their insomnia. If they have been prescribed these medicines on an ongoing basis there should also be a documented conversation where the patient has been counselled regarding discontinuation.

Identifying opportunities for Audit of Medical Practice

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s).
  • Change it to an aim.
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change.
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behavior

Review

Monitoring change and progress

It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practices complete the first part of the Audit of Medical Practice (CQI activity) Summary Sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended practices complete the remainder of the Audit of Medical Practice (CQI activity) Summary Sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).