Background The benzodiazepine receptor agonist zopiclone is by far the most widely prescribed hypnotic in New Zealand.¹ Despite its indication for the short term (up to 4 weeks) treatment of insomnia, many patients are prescribed zopiclone for much longer periods, with risks of tolerance, dependence, rebound insomnia, falls, drowsiness, and cognitive impairment.^{2 3}

Objectives To assess the frequency and quality of documented reasons for zopiclone prescription in primary care, to analyse these by demographic group, and to develop a strategy of individual prescriber feedback with the aim of reducing unnecessary prescribing.

Methods We conducted a retrospective review of prescribing records at a multi-prescriber primary care practice in rural New Zealand. Using available practice software (Medtech), all zopiclone prescriptions during 2022 were collated, enabling calculation of zopiclone tablets (7.5 mg) prescribed per individual per year, analysed by age, sex, and ethnicity. A random sample of 100 prescriptions were subject to chart review to assess frequency and quality of documented indication, risk discussion, duration of use, and consideration of non-pharmacological strategies.

Results Our search detected 942 zopiclone scripts for 394 individuals (4.1% of registered adult patients). Clinical records seldom included indications for zopiclone prescription (17%), comments regarding duration of use (16%), risks (5%), or sleep hygiene (3%). Just over half (51.8%) of patients were prescribed more than 30 tablets and 23.4% more than 180 tablets during the 12-month period. On average, patients aged 60 years or older were more likely to have excessive quantities prescribed, at volumes 1.84 times (p=0.0006) that of younger patients.

Conclusion Clinical justification for zopiclone prescription was notably poor in our sample, with documented discussion of non-pharmaceutical approaches detected in only a tiny minority of patients. Indications for use were generally absent or poorly described, suggesting inadequate diagnostic assessment, overtreatment, or both. Patients appear not to be receiving adequate information regarding the risks of, and alternatives to, long-term hypnotic use. These shortcomings are particularly relevant for older patients, with their typically high prescribing burden and increased risks of medication-related harm. These findings can be used to provide anonymised feedback to individual prescribers, an intervention known to reduce overprescribing.⁴

References

1. Pharmac. Year in Review 2022: Community medicines, number of funded prescriptions dispensed. https://pharmac.govt.nz/news-and-resources/order-publications/year-in-review/top-20s-for-202122/community-medicines/: New Zealand Government; 2021.

2. Medsafe. Zopiclone – Indicated for short-term use only. https://www.medsafe.govt.nz/profs/PUArticles/June2019/Zopiclone-Indicated-for-short-term-use-only.htm. New Zealand Government; 2019.

3. Yana J, Moscova L, Le Breton J, Boutin E, Siess T, Clerc P, Bastuji-Garin S, Ferrat E. Prescription of benzodiazepines and Z-drugs among older patients in primary care: a French, national, cohort study. Fam Pract. 2022 Oct 29:cmac114. doi: 10.1093/fampra/cmac114.

4. Rokstad K, Straand J, Fugelli P. Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice. J Clin Epidemiol. 1995;48(8):1061-8.