Motives for and Consequences of Long-term Prescription of Z-Drugs

Letters to the Editor The Role of Private Prescriptions in Benzodiazepine and Z-Drug Use—a Secondary Analysis of Office-Based Prescription Data by Thomas Grimmsmann, Karel Kostev, and Wolfgang Himmel in issue 21/2022

Grimmsmann et al. (1) show the substantial previously hidden numbers and increase in private prescriptions for Z-drugs. What possible motives underlie the prolonged prescribing far in excess of the recommended maximum duration of two weeks?

One motive might be a hitherto unrecognized behavioral dependence/addiction. In the inpatient population of a general hospital (cross sectional data collection 2014, n=400), 17 persons (4.75%; 76.1± 7.6 years; 76.5 % female) with Z-drug dependence and 0% with abuse (according to ICD 10) were found. This dependence had not been detected before. It existed for 8.1 ± 7.3 years and manifested as behaviorall dependence (craving, loss of control, narrowed/addictive behavior) as well as in physical dependence (withdrawal syndrome, development of tolerance) (ICD-10) from zopiclone (n=14)/zolpidem (n=3). The severity of the dependence was assessed as mild in 14 cases, moderate in 2 cases, and severe in 1 case. In four cases (23.5%), a de novo substance dependence was found, i.e., the first dependence on a substance ever in an individual’s history (2).

An additional motive for prolonged off-label prescription might be sustained improvement of chronic insomnia which was refractory before the Z-Drug had been prescribed, or poorly tolerated adverse effects from psychotherapy or another pharmacotherapy. I am, for example, treating five such persons (59–79 years with comorbid [3] depression, anxiety disorder, or somatization disorder; 3 female) as outpatients. All have been without relevant sleep problems for more than 5 years while taking (fluctuatingly) 3.75–11.25 mg zopiclone/night. They show mild physical withdrawal symptoms (which come to attention when attempting to reduce the dose) but no behavioral dependence.

DOI: 10.3238/arztebl.m2022.0315

Prof. Dr. med. Udo Bonnet
Klinik für Psychiatrie, Psychotherapie und Psychosomatik
im Evangelischen Krankenhaus Castrop-Rauxel
Akademisches Lehrkrankenhaus der Universität Duisburg-Essen
LVR-Klinikum Essen, Klinik für Psychiatrie und Psychotherapie,
Medizinische Fakultät der Universität Duisburg-Essen, Essen

References

1. Grimmsmann T, Kostev K, Himmel W: The role of private prescriptions in benzodiazepine and Z-drug use—a secondary analysis of office-based prescription data. Dtsch Arztebl Int 2022; 119: 380–1

2. Bonnet U, McAnally HB: How prevalent and severe is addiction on GABA-mimetic drugs in an eldery German general hospital population? Focus on gabapentinoids, benzodiazepines, and z-hypnotic drugs. Hum Psychopharmacol 2022; 37: e2822

3. Holzbach R, Brack J, Behrendt K: Indikationen für die Langzeitverschreibung von Benzodiazepinen und Z-Drugs. Suchtmed 2017; 19: 64–70.