GPs' attitudes to benzodiazepine and ‘Z-drug’ prescribing: a barrier to implementation of evidence and guidance on hypnotics (original) (raw)

. 2006 Dec 1;56(533):964–967.

Abstract

Zaleplon, zolpidem, and zopiclone (‘Z-drugs’) prescribing is gradually rising in the UK, while that of benzodiazepine hypnotics is falling. This situation is contrary to current evidence and guidance on hypnotic prescribing. The aim of this study was to determine and compare primary care physicians' perceptions of benefits and risks of benzodiazepine and Z-drug use, and physicians' prescribing behaviour in relation to hypnotics using a cross-sectional survey. In 2005 a self-administered postal questionnaire was sent to all GPs in West Lincolnshire Primary Care Trust. The questionnaire investigated perceptions of benefits and disadvantages of benzodiazepines and Z-drugs. Of the 107 questionnaires sent to GPs, 84 (78.5%) analysable responses were received. Responders believed that Z-drugs were more effective than benzodiazepines in terms of patients feeling rested on waking (P<0.001), daytime functioning (P<0.001), and total sleep time (P = 0.03). Z-drugs were also thought to be safer in terms of tolerance (P<0.001), addiction (P<0.001), dependence (P<0.001), daytime sleepiness (P<0.001), and road traffic accidents (P = 0.018), and were thought to be safer for older people (P<0.001). There were significant differences between GPs' perceptions of the relative benefits and risk of Z-drugs compared with benzodiazepines. The majority of practitioners attributed greater efficacy and lower side effects to Z-drugs. GPs' beliefs about effectiveness and safety are not determined by current evidence or national (NICE) guidance which may explain the increase in Z-drug prescribing relative to benzodiazepine prescribing.

Keywords: attitude, cross sectional studies, hypnotics and sedatives, physicians' practice patterns, prescriptions

INTRODUCTION

Most hypnotic prescribing takes place in primary care, and the use and cost of these drugs is rising. There are large variations in hypnotic prescribing,1 with some areas of the UK having higher levels of benzodiazepine and ‘Z-drug’ prescribing (hypnotics including zopiclone, zolpidem, and zaleplon) compared with national data.

There are potential side effects of hypnotic drugs, evidence of long-term use contrary to licensed indications, and lack of evidence distinguishing short-acting benzodiazepine and newer Z-drug hypnotics.2,3 The National Service Framework for Mental Health4 and the National Institute for Health and Clinical Excellence (NICE) in the UK5 advised monitoring of hypnotic prescribing and a cost-minimisation approach that would tend to favour short-acting benzodiazepine hypnotic use.

Despite NICE guidance, benzodiazepine prescribing rates have continued to fall over the past decade, and there has been a corresponding rise in the use of newer hypnotic drugs for insomnia over the same period.3 Although there has been considerable research into the attitudes of patients,6–9 doctors,10–12 and both13,14 regarding the use of benzodiazepines, there is limited published research on patients' and practitioners' perceptions of Z-drugs.

The aim of this study was to investigate and compare GPs' perceptions of benefits and risks of benzodiazepines and Z-drugs in one large primary care trust. This study was part of a larger study investigating the reasons for variations in hypnotic prescribing and exploring methods for reducing this in a primary care trust.

METHOD

West Lincolnshire Primary Care Trust has 40 general practices serving 214 000 patients. Prescribing of hypnotics is an important quality issue for all primary care organisations. Previous attempts to address prescribing in this area met with resistance to change. To address this the authors decided to explore practitioners' beliefs about hypnotic prescribing. A survey instrument, based on a search of the literature and an adaptation of a previously published instrument, was developed to collect data.13

In 2005 a self-administered postal questionnaire was sent to all GPs on the principal (independent practitioner) list of West Lincolnshire Primary Care Trust. The questionnaire focused on practitioners' perceptions of benefits and disadvantages of benzodiazepines and Z-drugs, and preferences for management of insomnia and anxiety. The questionnaire was developed using information from a review of the literature, discussion within the project steering group, and reference to experts in the field.

Returned questionnaires were entered into a spreadsheet according to a predetermined coding frame. Data were analysed using SPSS (version 12.1). Wilcoxon's signed ranking test was used for comparison of groups.

RESULTS

Of the 107 GPs who were sent questionnaires, 84 (78.5%) responded after one reminder. Characteristics of these GPs are described in Table 1.

Table 1.

Demographic data of GPs.

Characteristics n (%)
n 84 (100)
Sex
Male 57 (67.9)
Female 27 (32.1)
Age in years
25–34 12 (14.3)
35–44 29 (34.5)
45–54 35 (41.7)
55–64 8 (9.5)
≥65 0 (0)
Training status
Training 14 (16.7)
Non-training 70 (83.3)
Dispensing
Dispensing 36 (42.8)
Prescribing 48 (57.1)
MRCGP 45 (53.6)
Nurse prescriber in practice 47 (56.0)

How this fits in

The prescribing of Z-drugs continues to rise but that of benzodiazepines is falling. Whereas there has been research on doctors' perceptions of benzodiazepines, little is known about perceptions of Z-drugs or the drugs relative to each other. This study demonstrates that GPs believe that Z-drugs are more effective and safer than benzodiazepines despite published evidence and guidelines to the contrary. This is a potential barrier to implementation of national guidance on hypnotics.

Responders perceived that Z-drugs were more effective in terms of patients feeling rested on waking, daytime functioning, and total sleep time, and that they were less likely to lead to side effects, particularly tolerance, addiction, dependence, daytime sleepiness, and road traffic collisions. Z-drugs were also believed to be safer for older patients (Table 2).

Table 2.

GPs' perceptions of benefits and disadvantages of benzodiazepines and ‘Z-drugs’.

Benzodiazepines Z-drugs
Often or very oftena Not sure Rarely or intermittently/never Often or very often Not sure Rarely or intermittently/never _P_-valueb
Perception of associated benefits
Reduced time to get to sleep 61c 9 11 63 11 7 0.29
Reduced night-time waking 43 17 21 47 16 18 0.099
Increased total sleep time 31 22 26 38 23 20 0.030d
Feelings of being rested on waking 17 31 32 34 26 21 <0.001e
Improved daytime functioning 18 24 37 32 25 23 <0.001e
Improved overall wellbeing 30 19 31 29 27 25 0.320
Perception of associated side effects
Tolerance (patient needs increasing doses to maintain effect) 67 9 8 44 18 20 <0.001e
Addiction (withdrawal effects on stopping) 69 9 6 42 17 23 <0.001e
Dependence (patient reliance on drug) 84 5 5 59 8 15 <0.001e
Daytime sleepiness/sedation 49 18 17 17 23 42 <0.001e
Confusion 16 23 45 12 22 48 0.063
Cognitive impairment 16 19 47 44 16 22 0.130
Concentration problems 16 20 48 12 25 45 0.330
Falls 21 15 48 15 17 49 0.077
Hip fractures 17 17 49 15 15 21 0.200
Road traffic collisions 16 29 38 12 24 46 0.018d
Side effects more frequent in older patients 64 8 12 44 16 22 <0.001e

DISCUSSION

This was a study investigating prescribing preferences in a single primary care trust. The response rate from GP principals (independent practitioners) was high, adding to the validity of the findings in relation to local prescribing of these drugs. Although caution needs to be taken in generalising the results to other primary care organisations, the results are consistent with national changes in hypnotic prescribing.

There were significant differences between GPs perceptions of the relative benefits and risk of Z-drugs compared with benzodiazepines, with the majority of practitioners attributing greater efficacy and lower side effects to Z-drugs.

Practitioners' beliefs about relative indications, effectiveness, and safety are not determined by current evidence or national (NICE) guidance. Beliefs about evidence can prevent implementation of national guidance. The attitudes of GP responders in favour of Z-drugs help to explain the increase in prescribing of Z-drugs relative to that of benzodiazepines, a national phenomenon that is inconsistent with NICE guidance.

Despite GPs' positive attitudes to guidelines overall,15 NICE guidance continues to be variable in its implementation.16 Guidance has led to changes in prescribing of some drugs, and has been supported when it is consistent with previous practice.17 There is limited research into the effect of guidance based on new evidence that discourages past patterns of behaviour, as in this study which examined increasing use of Zdrug hypnotics. A number of factors have been identified as influencing adherence to prescribing guidance in general practice including relative safety, efficacy, practicability, and information conflicting with guidance, most importantly from the pharmaceutical industry.18

The targeted use of commercial techniques19 and meetings supported by pharmaceutical companies20 to proffer selected positive information about products early in their marketing, affects the attitudes of doctors and their prescribing behaviour.21–23 Despite professional concerns about the credibility of such information24 and the perceived immunity of some doctors to commercial influence,25 practitioners26 and their patients27 know that prescribing is being unduly influenced.

A number of approaches could be used to implement the NICE guidance and reverse current non-evidencebased trends in relation to hypnotic prescribing. Options include delivering a clearer message related to outcomes, communicating effectively using opinion leaders and other evidenced techniques, and enabling doctors and patients to understand the true relative advantages, disadvantages, and consequences of using these drugs28 and of non-pharmacological treatments. A clearer structural context is needed in health trusts supportive of implementation.17 Further research should investigate the relationship between prescribers' attitudes and actual prescribing, and examine how to change attitudes and behaviour to improve performance. GPs need to be aware of and discuss these beliefs in the context of available evidence to make informed and collaborative decisions about their prescribing practices for insomnia.

Acknowledgments

We thank GPs, the board and executive of West Lincolnshire Primary Care Trust for supporting this study. We are grateful to Dr Ross Upshur who provided a copy of his questionnaire developed for another study, and to Professor Anthony Avery, Dr Hugh Middleton, and Dr Michael Dewey for comments on earlier drafts.

Funding body

This study was funded with a Research Capacity Development Award from Trent Research and Development Support Unit and additional support from West Lincolnshire Primary Care Trust

Ethics committee

Approval was granted by Lincolnshire Research Ethics Committee Q4/Q2405/49 and research governance approval by West Lincolnshire Primary Care Trust

Competing interests

The authors have stated that there are none

REFERENCES