Sleeping tablets and Sedatives
Sleeping tablets and sedatives: why we are prescribing them less?
You may have heard that GP practices across Devon are reducing how often they prescribe medicines like, zopiclone, zolpidem, diazepam, lorazepam, temazepam and nitrazepam. Albany Surgery is one of them. This page explains what these medicines are, why the evidence has changed, and what it means if you are taking one now.
What are these medicines?
Benzodiazepines – diazepam, lorazepam, temazepam, clonazepam, midazolam are sedatives. They can help for a few days with severe anxiety, muscle spasm, seizures or alcohol withdrawal and in end of life care.
“Z-drugs” – zopiclone, zolpidem are sleeping tablets. They are not benzodiazepines, but they act on the brain in a very similar way and carry the same problems with long-term use.
Both are controlled drugs and both are licensed for short-term use only, usually no more than two to four weeks, which includes the time it takes to come off them.
Why we are changing how we prescribe?
- Local data shows that Devon as a whole is a national outlier, with 1.22% of the population prescribed one of these medicines compared with 0.80% nationally.
- We are not alone in tackling this, all practices across Devon have been tasked to reduce their prescribing of these medications to improve safety.
- The honest answer is that the benefit is smaller than most people expect, and the risks are larger.
Research on Z drugs summarised by the NHS puts it like this. Imagine 13 people aged 60 or over with insomnia are all take a sleeping tablet for at least five nights:
– Of these 13 people about 1 person sleeps better. On average they get just an extra 25 minutes’ sleep a night, and wake once less often every other night.
– About 2 people get side effects that they would not have had otherwise: drowsiness, headache, nightmares, nausea or stomach upset.
– The other 10 people get no benefit at all, compared with a placebo tablet.
Z-drugs and benzodiazepines also carry some significant harms:
– Falls and fractures – These medicines roughly double the risk of falls in older adults.
– Dependence/Addiction – The Royal College of Psychiatrists estimates that around 4 in every 10 people, who take them daily for more than six weeks will become dependent/addicted.
– Tolerance – Over months the same dose stops working, so the medicine keeps being taken without it helping.
– Memory, mood and thinking – Long-term use is linked to poor concentration, low mood and memory problems that can be mistaken for dementia.
– Increased risks/side effects in combination with other medications – The MHRA, the UK medicines safety regulator, warns that benzodiazepines and Z-drugs when taken with opioid painkillers (codeine, morphine, tramadol) can cause breathing to slow, which can be fatal in some instances. The two should only be taken together where there is no alternative.
When we might still prescribe a short course
After a discussion with your GP, and once other options have been tried, a short course of a few days of benzodiazepine or zopiclone may occasionally be appropriate for:
– Severe insomnia, after sleep hygiene advice, online cognitive behavioural advice CBT and other treatments have been explored (such as daridorexant, melatonin and so on).
– Muscle spasm in back pain (3-5 day course), if this has genuinely helped before
– An acute crisis, for example bereavement
These will be issued as, one-off acute prescriptions with a clear end date and at the lowest dose (eg 2mg for diazepam and 3.75mg for Zopiclone). They will not be added to your repeat list and will not be for recurrent issue.
When we will not prescribe
– Fear of flying. Sedatives slow your reaction times in an emergency, increase the risk of blood clots on long flights, and are illegal to carry into some countries. Airline-run courses have far better results. See flyingwithconfidence.com.
– MRI scans, hospital procedures or dental work. The team carrying out the procedure is responsible for any sedation, and is trained to monitor you safely. Please contact them directly.
– Ongoing anxiety. The National Institute of Clinical Evidence (NICE) advises against benzodiazepines for generalised anxiety and panic disorder, because outcomes are worse in the long run. We will talk to you about other treatments that work better.
If you are already taking one of these medicines
Please do not stop suddenly, stopping abruptly can be unpleasant and, in some cases, unsafe, in most cases a gradual reduction and withdrawal of medication is the best approach.
We will gradually be arranging for patients on long-term prescriptions to have a medication review with our practice pharmacist or GP. Together you and clinician will discuss the risks and benefits and arrange a gradual reduction in medication dose/strength. Reductions go at a pace you can manage, and can be paused, It can take many months, sometimes up to 18months to come off of these medications, fortunately many people who reduce gradually find they sleep no worse, and often feel sharper during the day.
Please do be aware that if you request your medication early or have taken more than is advised on your prescription, you may be switched to shorter duration issues of your medication eg 7 or 14 days, this is part of safe prescribing procedure and not a judgement on you. From time to time patients may also be asked to sign a prescribing agreement, that explains the risks of the medication and how often it will be issued and in what circumstances it will not be issued.
Driving and/or operating heavy machinery whilst taking these medications
Diazepam, lorazepam, temazepam, oxazepam, clonazepam and flunitrazepam are named in drug-driving law, which sets blood limits. If you take your medicine exactly as prescribed and your driving is not impaired, you have a medical defence. It remains an offence to drive while impaired by any medicine. Zolpidem’s product information advises not driving for at least eight hours after a dose. If you are unsure, speak to us or to your pharmacist.
Where to find out more
For further advice and a list of resources that can support you with insomnia and mental health please click here to access our page on insomnia resources:
– Patient.info: Benzodiazepines and Z-drugs:
https://patient.info/mental-health/insomnia-poor-sleep/benzodiazepines-and-z-drugs)
– Mind: Sleeping pills and minor tranquillisers
– Talk to FRANK: Benzodiazepines
https://www.talktofrank.com/drug/benzodiazepines
– NICE guideline NG215: Medicines associated with dependence or withdrawal symptoms
