Sedative hypnotics warrant respect—prescribe them sparingly

The Inquiry Committee recently investigated a case referred to it by the chief coroner—an unintended death due to a mixed overdose, primarily zopiclone. A review of the patient’s PharmaNet record confirmed excessive quantities of zopiclone and identified five prescribers: four family physicians and a surgeon. Most of the visits were at walk-in clinic settings. Contrary to the College’s expectations outlined in the professional standard, Walk-in, Urgent Care and Multi-physician Clinics, none of the physicians had consulted PharmaNet. Even so, it ought to have been clear that the patient was exceeding the maximum dose of 7.5 mg and using it daily. Further, none of the physicians had documented any attempt to assess for addiction to zopiclone or other substances, or to counsel the patient on the inappropriateness of her use of the drug, and the availability of addiction services.

Sedative hypnotics are hazardous when combined with opioids, alcohol or other sedating drugs. Risk increases with dose while tolerance develops early. Hypnotics facilitate sleep onset, but not the quality of sleep, or of daytime functioning. They are indicated for short-term use only and generally contraindicated in the elderly. Hypnotics are associated with increased all-cause mortality, even when health status is taken into account. (See Hypnotics’ association with mortality or cancer: a matched cohort study.) Patients taking hypnotics deserve to know that the hazard ratio is similar to smoking.

Despite marginal effectiveness, many patients quickly come to overvalue their sleeping pills and pressure physicians to over-prescribe. College standards are in place to support physicians in the often-uncomfortable task of resisting. With rare exceptions (notably end-of-life care), the Inquiry Committee expects physicians to

  • limit hypnotics to short-term, intermittent use,
  • not exceed maximum doses set out in product monographs and other references,
  • keep dispenses modest; 10 doses are suggested—fewer if the patient is not known to the physician,
  • decline to prescribe to patients who cannot be relied upon to abstain from alcohol and other sedatives, including patients with a lifelong disease of addiction, and
  • always review PharmaNet before prescribing if they work in walk-in settings or the ER.

Physicians prescribing to patients with chronic non-cancer pain should be familiar with this list of Prescribing Principles.

The College’s Prescribers Course utilizes standardized patients to assist physicians in improving their management of these difficult conversations. In the case described above, the Inquiry Committee directed that all five physicians under review attend the course, which the College recommends as useful continuing medical education for all physicians. Three of the five must also complete the College’s Medical Record Keeping Course. All of the walk-in clinic physicians must implement PharmaNet.