How do general practitioners express the barriers to appropriate prescribing of Z-drugs and benzodiazepines: a meta-synthesis of existing research

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How do general practitioners express the barriers to appropriate prescribing of Z-drugs and benzodiazepines: a meta-synthesis of existing research

INTRODUCTION

Inappropriate prescription of drugs is very common, especially among old people, yet it is preventable. Old people have increased multimorbidity and suffer more from adverse drug events such as cognitive impairment, which increases the utilisation of health resources and the risk of adverse drug events [1]. Use of medication is said to be inappropriate when the risks of the adverse drug events outweigh the clinical benefits. Moreover, excessive dose, prescription of drugs for a prolonged duration and medication prone to drug-drug interaction is said to be inappropriate [2]. Long term use of benzodiazepines were identified as the most common potentially inappropriate medications (PIM) [3]. Benzodiazepines (BZDs) and Z-drugs are types of hypnotic medications which cause the partial loss of consciousness or sleep in a person [4]. Under prescription, the hypnotics are used in people with severs insomnia for the short-term period [5]. According to the British National Formulary, the most commonly used anxiolytics and hypnotics are benzodiazepines and their working mechanism is that they bind to GABA receptors on benzodiazepine receptors in the brain, causing the induction of sleep. The BNF lists flurazepam and nitrazepam as long acting, and loprazolam, temazepam and lormetazepam as short acting hypnotics, while oxazepam, diazepam and lorazepam treat insomnia associated with daytime anxiety [5].

On the other hand, non-benzodiazepines are newer drugs that can be used in the improvement of insomnia as they are used in short-term treatments [4]. Their main treatment is based on causing the onset of sleep faster, thus allowing the sleep period to be longer. The drugs have less chance of causing tolerance, dependency and impairing daytime activities due to their short half-life. Thus, they are better with fewer side effects compared to benzodiazepines. Some non-benzodiazepines are Zolpidem, Zaleplon and Zopiclone [5]

These drugs are supposed to be taken under the direction of the doctor since taking them without proper consideration from the doctor may lead to sedation (excessive drowsiness) or even death [4]. In general, BZDs and Z-drugs are effective and safe medications for anxiety disorders and insomnia. However, using them in the long-term may lead to different side effects and dependence [5]. According to the National Institute for Health and Care Excellence (NICE) technology appraisal guidance “general practitioners should prescribe hypnotics for only a short period if they find that it is an inappropriate way of treating insomnia and interferes with normal life. They should take into account the required daily dose and withdrawal should be gradual. If treatment with the one hypnotic does not work, the drug should be stopped immediately, and they should not prescribe another”.

The prescription of hypnotic drugs has been common and is increasing. According to Weich et al. (2014), benzodiazepine (BZD) prescriptions account for 62% and Zaleplon, Zopiclone and Zolpiderm (Z-drugs) account for 32% of the total hypnotics prescribed in England [6]. They are often prescribed by general practitioners (GP) [7]. Reviews of studies on using benzodiazepines in primary care in Europe and other countries made conclusions on the long-term use of benzodiazepines as a common phenomenon [8].Despite the guidance by National Institute for Health and Clinical Excellence (NICE) on short-term use of the drugs, studies show that general practitioners (GPs) overprescribe benzodiazepines for extended periods [9].

Using hypnotic drugs may be helpful for people with sleeping difficulty, but there has been evidence of adverse effects in people that use them. Various studies show that in the elderly inappropriate prescriptions of medications leads to adverse health outcomes. Though not only ineffective, long-term use of hypnotics increases the risks of undesirable effects [10], including: increasing risks of cancer [11], dementia [12], daytime fatigue, road traffic accidents, falls and ataxia [13], and other infections [12]. In addition, hypnotics lead to dependence and tolerance, making it difficult to withdraw from them. Long-acting or short-acting benzodiazepines result in withdrawal syndrome, characterised by anxiety, insomnia, tremor, loss of appetite, tinnitus and perspiration. For the short-acting hypnotics, withdrawal syndrome occurs within a day while in long-acting it occurs any time after three weeks following withdrawal. It should be withdrawn gradually because when withdrawn abruptly it may lead to convulsions, toxic psychosis and confusion [5].

Liffe et al. observed that sixty percent of patients at a long-term care facility had been prescribed hypnotics for 10 years or more while 30 percent had used them for more than two decades [14]. On the other hand, the rate of prescription for benzodiazepines have fallen drastically in the UK over the past decade with corresponding rise in use of newer hypnotics in the treatment of insomnia [15]. This trend is contradicting the NICE which advised using short acting benzodiazepine hypnotics as a way of cost minimisation approach [16]. However, there are variations in the implementation of NICE guidance that might lead to changes in drug prescriptions.

Questions have been raised on what influences the decisions of clinicians on the initiation, withdrawal or continuation of a benzodiazepine prescription [8]. There are variations on the prescribing rates between clinicians and practices, with an explanation being partly due to clinician attributes, demographics of patients and differences in the organisation of general practice [17]. Attempts to influence doctors’ prescribing behaviours must have a basis of understanding the prescribing decisions that are actually made thoroughly [18]. Sirdifield et al. (2013) explored the experiences and perceptions of clinicians on the prescribing of benzodiazepine for the building of an exploratory model of processes. It was shown that prescribing decisions made by general practitioners have a context of uncertainty with consultation pressures and short timescales [8]. Siriwardena et al. (2010) conducted a study and established that the general practitioners had positive attitudes towards the reduction of Z-drug and BZD prescriptions for insomnia but negative attitudes towards hypnotic medications [7].

The action of stopping the prescription of medications over months to years by many factors is complicated in relation to the prescribing practitioners and their patients. For effective strategies that would lead to stopping inappropriate prescribing, there needs to be development of an understanding. Some patient barriers to and enablers of not prescribing were identified, though there is still no comprehensive review of the perspectives of prescribing practitioners [19]. A review of literature has found that there are a number of interventions that can reduce the prescribing and use of benzodiazepines [20]. However, most of the interventions require high skill levels and use of resources in which widespread use would not be feasible [10]. Mugunthan et al (2011) recommended a simpler, cheaper intervention method whereby interventions are used. They conducted a review and found that using BZDs in the long-term can be reduced by the use of minimal interventions like a consultation or a simple tailored letter, which highlights the recommended continuation or discontinuation of prescribed drugs. They found that the effectiveness of the letters is decreased when the list of patients generated by the GP is inappropriate. The recommendation given by Mugunthan et al (2011) was for a strategy that would be clinical and economical [10].

For clinicians and GPs, it is evident that inappropriate prescribing of hypnotics is a significant problem that worsens the health of the elderly [6]. Various studies conducted and reviewed have disclosed the perceptions of practitioners in terms of their own cognitive processes and of patients as some of the factors that shape their behaviours in prescribing hypnotics [20]. Through the study of Anderson (2014), a clear conceptual framework is provided that helps us to understand such behaviours of continuing or discontinuing prescriptions of hypnotics for long-term use. There is note of the lack of intervention studies that stop the prescribing of hypnotics in the identification and account of enablers and barriers [20].

Different behaviour change models and techniques have been applied in understanding a person’s health behaviour and come up with design interventions to change the habits. The capability- opportunity -motivation (COM-B) model can be used to address the problem of lack of combination; it is used as a guide on how best low-intensity interventions are carried out. The model sets out that a person’s behaviour results from the integration of the capability to execute the act of the opportunity that the person has in the performance of the behaviour and finally the motivation towards performing the action (21). The model asserts that the occurrence of a new behaviour is contributed by all of the aspects, for example, an opportunity and capability can influence motivation. Similarly, enacting behaviour alters motivation, opportunity and capability (21). The purpose of the study is to explore how can general practitioners express the barriers to achieve appropriate prescribing of benzodiazepines and z-drugs using COM-B model

METHODS

Information sources and searches

A comprehensive search of the published literature was conducted to identify all studies that had examined the attitudes of general practitioners (GPs) towards the prescribing of hypnotics in the adult population. During September to October 2015, the databases CINAHL, Medline (PubMed), PsycINFO, SCOPUS, Web of science, Science Direct, ProQuest and Springer were searched for articles published between 2000 and 2015 on this subject. In addition to the academic databases listed above, the search engine GoogleScholar was used in an attempt to capture studies published online which were not at first identified by the more traditional means. The reference lists of all important articles were also scanned to check for other relevant studies that may have been missed via database searching.

A variety of search terms was constructed for use within the databases including: hypnotics and sedatives (MeSH term), sedatives OR Hypnotic Effect, hypnotic Effect OR Effect, Hypnotic, general practitioners (MeSH term), Practitioner, General OR Practitioners, General, view or attitude (MeSH term), stopping (MeSH term), treatment discontinuation, treatment cessation, benzodiazepine (s), benzodiazepine compounds, non-benzodiazepine (s), z-drugs, zopiclone, zolpidem, zaleplon, eszopiclone and barriers or enablers. These terms were combined suitably according to the databases used. A number of additional terms potentially portraying GPs attitude of hypnotic medications were later identified through the articles retrieved and these were additionally inputted into the databases, but did not increase the yield of articles: appropriate prescribing, inappropriate prescribing or reducing, practice patterns, prescription, prescribing, and stopping or optimizing medications. The details of the search and retrieval strategy are outlined in figure 1.

Study selection

The title and abstracts of all articles initially identified (997) were scanned after duplicates (71) were removed. Studies of any design that had explored the general practitioners attitude or perception, the barriers to implementation of evidence and guidance on or the discontinuation programme of hypnotic medications among adults or older patients published from 2000 to 2015 were included for initial review. A total of 115 papers were selected for full text assessment from which 19 were included in this review. Additional 3 papers were identified by searching reference lists of retrieved articles and GoogleScholar search. So a total of 22 research papers were included eventually in this review. We chose to include papers with different epistemological bases because we wanted to gain in-depth information about the practice of general practitioners among patients with insomnia which could include qualitative as well as quantitative data.

Inclusion and exclusion criteria

The inclusion of studies was based on their involvement of qualitative or quantitative analysis, of general practitioners or their perceptions and experiences in the prescription of z-drugs and benzodiazepines. With the need to customize the search settings for the relevant and recent ones, the limits were defined for English language, articles dated from 2000 to 2015. This would ensure that the publications were relevant to the history of benzodiazepine and z-drugs prescription and current practice and conducted in the United States, Europe, Australia or New Zealand. The exclusion criteria were based on publications that were outside the primary care setting, the English language and the dates.

Data abstraction, appraisal and synthesis

The papers included in this review were analysed in line with qualitative review methodology [17] to produce a number of themes that reflect published knowledge about general practitioners experience of hypnotic prescriptions. A grid was created to record summaries of the articles for conceptualization and construction of the literature review. This initial tabulation presented information on study characteristics including the year of study, the study sample, country where research took place, research design, and a brief description of study aims (see table 1). The full text of all included articles was reviewed and any information benzodiazepines or z-drugs was extracted for further analysis. Data from papers included in the review and relating to the GPs’ perceptions of, and barriers to appropriate prescription of hypnotics were grouped into three categories:

The quality of the studies was evaluated with criteria based on that established by Hawker et al [18]. The critical appraisal tool consists of a nine-item checklist to evaluate the quality of both qualitative and quantitative studies. Accordingly, in order to assess the quality of the studies, for each article the title and abstract, introduction and aims, methods and data, samplings, data analysis, ethics and bias, results, transferability and generalizability, and implications and usefulness were all individually rated as either good (g), fair (f), poor (p) or very poor (vp) before returning a total score for each of these categories relating to that article (see table 2). The scoring system then allowed comparison of articles so that for example, a study scoring “g=7, f=1, vp=1” could be judged of better quality against one scoring “f=4, p=3, vp=2”. The quality of the included studies in this review varies widely. The aim of this review was to capture a wide and practical picture of the experience …. COMPLETE 2 OR 3 SENTENCES

References

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2. Spinewine, A. Schmader, K. E. Barber, N. Hughes, C. Lapane, K. L. Swine, C. Hanlon, J. T. 2007 appropriate prescribing in elderly people: how well can it be measured and optomised Lancet 370(9582): 173-184.
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15. National Institute for Health and Clinical Excellence. Guidance on the use of zaleplon, zolpidem and zopiclone for the short term management of insomnia. Technology Appraisal Guidance 77. London: NICE, 2004.
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18. Anderson, K., et al. (2014). “Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.” BMJ Open 4(12): e006544.
19. Voshaar, R. C., et al. (2006). “Strategies for discontinuing long-term benzodiazepine use: meta-analysis.” Br J Psychiatry 189: 213-220.

1. Siriwardena, A. N., Qureshi, Z., Gibson, S., Collier, S. & Latham, M. 2006. GPs’ attitudes to benzodiazepine and ‘Z-drug’ prescribing: a barrier to implementation of evidence and guidance on hypnotics. British Journal of General Practice, 56(533), 964-967.

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Table 2 description of studies included in the review

Figure 1. The literature search strategy and identification of publications included in this review

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