3 Cognitive behavioral therapy (CBT) has been shown to be as effective as pharmacological treatments, however, combinations may be better. If non-pharmacological interventions fail or insomnia causes significant daytime dysfunction and distress then hypnotics may be used.
2 They have been used as hypnotics since the 1960s and when compared with a placebo, produce a marked and clinically meaningful effect on sleep duration. A meta-analysis comparing collided and benzodiazepines found for patients 65 years old and younger they were equally effective as a placebo, but for patients older than 65 years both had an increased risk of adverse effects.
5 Similarly, studies comparing hypnotic properties found zopiclone (a cyclopyrrolone) is equal to or superior than benzodiazepines. These benefits (i.e. fewer adverse effects and rebound insomnia, less psychomotor impairment and much less residual impairment improving daytime functioning) outweigh the risks associated with zopiclone.
6 Adverse effects of benzodiazepines include headache, blurred vision, gastrointestinal upset, confusion, ataxia and paradoxical reactions, which outweigh their potential clinical benefits. 2 It looked at the most commonly reported adverse effects, which were more frequent for the benzodiazepines, and included somnolence, headache, dizziness, nausea and fatigue.
Hangover effects of hypnotics are dose-dependent and vary depending on pharmacokinetics, i.e. duration of action, which is determined by elimination half-life (most likely if greater than six hours, e.g. diazepam and zopiclone due to residual drug in the brain), as well as individual susceptibility, i.e. rate of drug clearance. Collided can, dose-dependently, impair word recall and recognition 6–8 hours post-administration after which the risk is reduced.
12 Comorbid respiratory impairments such as COPD and obstructive sleep apnea may be exacerbated by benzodiazepines. 12,18 Historically-used hypnotics, e.g. choral hydrate, chlormethiazole and barbiturates, have the potential to cause lethal respiratory depression in overdose due to their low therapeutic ratios, and their effects are very difficult to reverse, so they are no longer recommended.
One major patient safety concern is impaired driving performance, which may be hypnotic-induced or sleep-deprivation-induced. Benzodiazepines, as well as zopiclone and collided, increase the risk of road traffic accidents.
9 The risk is more than doubled in zopiclone and collided users compared with unexposed drivers. The FDA 22 issued a similar announcement for extended-release collided, as residual levels are high enough to cause impairment especially at higher doses.
Zopiclone may also induce driving impairment the morning after or in the afternoon following a 15 mg dose. 13 Moreover, long-acting benzodiazepines are more likely to cause next-day driving impairments than collided, zopiclone, diazepam, and non-users of hypnotics, for example flunitrazepam has been associated with four times the risk of a road traffic collision.
They tend to have a reduced renal and/or hepatic function, which can prolong drug metabolism, elimination and action. In addition, their receptors are more sensitive and even short-acting GABA-ergic drugs can compromise balance and decision-making during the night.
There is at least a 50% increased risk of hip fractures when benzodiazepines are used in the elderly, especially during initial treatment and after continuous use (>1 month). The risk is increased with chronic use of shorter-acting hypnotics at higher doses, a history of substance dependency, personality disorders and no medical supervision.
NICE 5 estimates that 10–30% of patients taking benzodiazepines chronically are physically dependent and at least a third experience problems on stopping or reducing the dose. 2 This includes transient worsening of insomnia, headaches or myalgic, confusion, and severe anxiety, restlessness, and irritability.
Consideration of patient characteristics as well as pharmacokinetic differences between drugs before offering a hypnotic is vital. This caution should be explained to patients along with information about the hypnotic prescribed to limit abuse potential.
Ms Agra vat is a clinical mental health pharmacist at Penning Care NHS Foundation Trust, Ashton-under-Lyne. This was submitted as part of University of Aston Certificate in Psychiatric Therapeutics.
British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. Taylor D, Peyton C, Kanpur S. The Mandela Prescribing Guidelines in Psychiatry.
New advice to minimize risk of next-morning impaired driving ability and mental alertness with collided. Committee on Safety of Medicines: UK Government Bulletin to Prescribing Doctors, January 1988, Benzodiazepines, dependence and withdrawal symptoms.
Nut D, Fee tam C. What one hand given the other take away: some unpredicted effects of enantiomers in psychopharmacology. Benzodiazepines, also known as BZS or Bezos, are commonly prescribed for anxiety, insomnia, muscle tension and a variety of other problems.
All share a common chemical structure and all achieve their desired effect by modifying a specific receptor site on neurons. According to the National Institute of Health, between 1996 and 2013, the number of adults who filled a benzodiazepine prescription increased by 67%.
Benzodiazepines have been associated with a range of negative outcomes, including decreased quality of life, increased overall mortality, suicide, and death related to opioid overdose. According to the American Psychiatric Association, physiological dependence and a resulting withdrawal syndrome may be seen in to up 80% of patients who use benzodiazepines long-term.
Please see The Language of Harmful Use for an overview of this difference, and the Terminology page for a detailed description of each of these terms. Salman C. The APA Task Force report on benzodiazepine dependence, toxicity, and abuse.