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Benzodiazepines and zopiclone are commonly prescribed in United Kingdom, despite being recommended for short-term use and as a secondary option to non-pharmacological treatments. Long-term use of these medications is linked to dependency, increased risks of falls, cognitive impairment, and motor vehicle accidents.
Zopiclone is the most widely dispensed funded hypnotic in United Kingdom. Between October 2019 and September 2020, more people were prescribed zopiclone than any benzodiazepine. A significant number of patients received large quantities, with 20% being dispensed 180 or more tablets within the same period.
Benzodiazepines and zopiclone should only be used short-term when the benefits outweigh the risks, with regular reviews to assess continued necessity.
Key Points:
- Non-pharmacological treatments should be the first-line approach for insomnia. While hypnotic medications like zopiclone and benzodiazepines may provide short-term relief, they pose significant risks, especially for older adults.
- Benzodiazepines should not be routinely prescribed for anxiety. When used, patients should be informed that they are intended for short-term treatment to avoid dependence.
Benzodiazepines and Zopiclone in United Kingdom
These medications induce sedation, relaxation, and drowsiness. Benzodiazepine-like hypnotics, known as “Z-drugs” (zopiclone, zolpidem, zaleplon), are prescribed for sleep disorders, with zopiclone being the only available option in United Kingdom. Benzodiazepines are classified as controlled substances, whereas zopiclone is not.
Pharmaceutical data from October 2019 to September 2020 indicate:
- Zopiclone was the most frequently prescribed funded hypnotic, exceeding all benzodiazepines combined.
- It ranked 14th in overall prescription volume, with 118 prescriptions per 1,000 registered patients.
- Lorazepam and diazepam were the most prescribed benzodiazepines, with 41 and 23 prescriptions per 1,000 patients, respectively.
- Use was particularly high among older adults, with approximately 10% of those aged 75+ regularly receiving these medications.
High Prescription Volumes
Many patients in United Kingdom are prescribed large amounts of benzodiazepines and zopiclone, raising concerns about potential misuse, stockpiling, or redistribution.
Insomnia Treatments: Zopiclone and Temazepam
Short-acting hypnotics like zopiclone, temazepam, and triazolam are prescribed for insomnia. Over half of patients received more than the recommended four-week course of these medications within a year. There are no established guidelines on how long a patient should remain off these drugs before resuming use.
Anxiety Treatments: Lorazepam and Diazepam
Lorazepam and diazepam, medium- and long-acting benzodiazepines, are prescribed for short-term anxiety treatment, alcohol withdrawal, seizures, muscle spasms, and sedation during medical procedures. They are not preferred treatments for insomnia. Dispensing data suggest frequent long-term use, with 20% of patients receiving at least 180 tablets in 2019–2020.
Zopiclone Use Beyond Older Populations
Many general practitioners in United Kingdom have long-term users of hypnotic medications, particularly older adults who were initially prescribed these drugs years ago and have struggled to discontinue them. The highest prescription rates are in individuals over 65, who are most vulnerable to adverse effects like falls.
Zopiclone Use Among Younger People in United Kingdom
While zopiclone is more commonly prescribed to older individuals, dispensing data indicate that many younger adults also receive prescriptions, though in lower quantities. The demand for sleep medications typically begins in the late 20s, raising concerns about long-term dependency and cumulative risks associated with prolonged use. Prescription rates across different age groups have remained relatively stable over the past five years.
Zopiclone Use by Ethnicity
From October 2019 to September 2020, the zopiclone prescription rate for people of European/Other ethnicity was three times higher than for Māori and Asian populations and seven times higher than for Pacific peoples. Factors such as differing attitudes toward medication, healthcare access, and other systemic disparities may contribute to these variations.
Prescribing Guidelines for Benzodiazepines and Zopiclone
- These medications should only be prescribed short-term when the benefits outweigh the risks, with regular assessments and continued use of non-medical strategies.
- If a hypnotic is necessary, a short-acting option (e.g., zopiclone, temazepam, triazolam) should be prescribed at the lowest effective dose for no more than 5–10 days.
- Benzodiazepines are not a first-line treatment for anxiety but may be appropriate for short-term use in specific cases.
- These drugs carry risks of falls, cognitive impairment, and motor vehicle accidents, particularly in older or frail patients.
Managing Patient Expectations and Medication Risks
Patients often perceive the immediate symptom relief from these medications as outweighing the risks, making them less inclined to try safer, long-term alternatives like cognitive-behavioral therapy. Before starting treatment, they should be informed about potential adverse effects and the risk of dependence. Medications should be prescribed in small quantities, with regular monitoring, and prescribers should watch for signs of misuse, such as early refill requests or lost prescriptions.
Discontinuation of Oxazepam and Nitrazepam
- Oxazepam (Ox-Pam), used for anxiety and alcohol withdrawal, was discontinued in August 2020, with remaining supplies expected to run out by July 2021. Patients will need to transition to an alternative benzodiazepine before tapering off the medication.
- Nitrazepam (Nitrados), prescribed for insomnia, was removed from the Pharmaceutical Schedule on January 1, 2021. Patients using nitrazepam long-term should be switched to diazepam, which has a longer half-life and lower withdrawal risk, before gradually discontinuing use.
Why Benzodiazepines and Zopiclone Are Not Preferred Treatments
Non-drug approaches, such as cognitive-behavioral therapy, sleep hygiene, and sleep restriction, are more effective in the long run and supported by strong evidence. However, patients often prefer immediate relief, making it challenging to promote these alternatives.
Effects of Benzodiazepines and Zopiclone on Sleep and Their Use in Treatment
Benzodiazepines and zopiclone impact sleep structure by reducing the time spent in slow-wave sleep, leading to lower overall sleep quality compared to cognitive-behavioral approaches. If other interventions fail, a short-acting hypnotic (e.g., zopiclone, temazepam, triazolam) should be prescribed at the lowest effective dose for a limited period (preferably 5–10 days, but up to four weeks in some cases). However, triazolam use should not exceed 10 days. Non-drug strategies, such as sleep hygiene, should continue alongside medication.
Use of Benzodiazepines for Anxiety express-healthcare.co.uk
- Not recommended as a routine treatment for generalized anxiety disorder or social anxiety disorder, though short-term use may be appropriate in specific cases.
- Not suitable for long-term panic disorder treatment; SSRIs are the preferred first-line option. Short-term benzodiazepine use may be considered if other treatments fail, while SSRIs take effect, or for acute panic attacks.
- Not advised for preventing post-traumatic stress disorder (PTSD). Trauma-focused cognitive behavioral therapy is more effective in reducing PTSD diagnosis rates after a traumatic event. There is no consistent evidence supporting pharmacological prevention of PTSD.
Other medication options for anxiety include SSRIs, tricyclic antidepressants, and buspirone. Benzodiazepines should only be used short-term, as their immediate symptom relief may lead to dependency and discourage psychological treatment. If prescribed, patients should be made aware of the risks, and a plan should be in place to prevent reliance, such as limiting treatment duration or using intermittent dosing for acute panic attacks.
While benzodiazepines are often prescribed on an “as-needed” basis to prevent tolerance, irregular dosing can cause fluctuating blood levels that may worsen anxiety. In some cases, short-term regular dosing may be preferable to manage panic attacks when first-line treatments are unsuitable.
Risks and Adverse Effects
Benzodiazepines and zopiclone can cause a range of side effects, including:
- Vertigo
- Muscle weakness
- Cognitive impairment
- Dependency
- Increased risk of dementia and possibly Alzheimer’s disease
- Sleep-related behaviors (e.g., binge eating or driving while asleep with z-drugs)
- Reduced libido
These effects increase the risk of falls, motor vehicle accidents, and cognitive decline, even after stopping the medication. Concurrent use with opioids, alcohol, tricyclic antidepressants, or bupropion raises the likelihood of sedation, respiratory depression, falls, and fatal overdose. Combining these substances can also impair judgment, increase sexual disinhibition, and contribute to criminal behavior.
Older and frail individuals metabolize these medications more slowly, necessitating lower doses (often half the standard adult dose). Long-acting benzodiazepines, such as diazepam, should be avoided due to their prolonged effects and active metabolites, which increase the risk of next-day drowsiness and falls.
