Dear Sir,
Since the publication of the Ministry of Health's Clinical Practice Guidelines ’Prescribing of Benzodiazepines’[1] and ’Administrative Guidelines in Insomnia’[2] in 2008, there has not been any further update or local official guideline on this pertinent issue. Benzodiazepines and other sedative hypnotics are addictive and have adverse side effects.
To promote safe and responsible prescription, the Section of Addiction Psychiatry of the College of Psychiatrists, Singapore, and the National Addictions Management Service, Singapore, have worked together to produce the following set of good practice recommendations. It is a consensus among professionals working together in the field of addictions and presents a working set of recommendations for general practitioners (GPs) and non-psychiatrists working in Singapore.
Benzodiazepines and ’Z-hypnotics’ (e.g. zolpidem, zopiclone) should not be used as first-line agents for the management of insomnia. GPs should discuss sleep hygiene[3] with patients.
A course of sedating antihistamines, melatonin or sedating antidepressants may be considered. The side effects of such medications need to be discussed with patients.[4] It is recommended that their use be limited to a short course (2–4 weeks).
A short (2–4-week) course of benzodiazepines may be considered for acute insomnia. Shorter-acting benzodiazepines (e.g. alprazolam) have a higher addictive potential than longer-acting ones.[5] However, longer-acting benzodiazepines may cause daytime sedation. As such, their risks and benefits should be considered.
Patients with acute insomnia should not be prescribed more than one type of sedative hypnotic.
The mainstay of treatment for chronic insomnia is cognitive behavioural therapy for insomnia (CBT-I),[6] and patients should be referred for professional help with a psychologist trained in CBT-I.
Patients with chronic (>3 months) insomnia should be referred to a specialist for thorough evaluation.
For patients with chronic insomnia who are already on benzodiazepine or ’Z-hypnotics’ for many years, dosage reduction should be considered. These patients should be referred to psychiatrists, as they could be dependent on such drugs.
Benzodiazepines should not be the first line of treatment for anxiety disorders and should not be prescribed as monotherapy for anxiety disorders.
When prescribed for severe anxiety, benzodiazepines should be prescribed at their lowest effective dose for the shortest period of time, and should be avoided if the anxiety is mild.
Dosage of benzodiazepines and ’Z-hypnotics’ should be reduced in the elderly (>65 years old).
Benzodiazepines and ’Z-hypnotics’ should generally not be prescribed to patients with substance use disorders.
The risk of developing dependence and long-term side effects of benzodiazepines and ’Z-hypnotics’ should be discussed with patients and documented.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Ministry of Health, Singapore. Prescribing of benzodiazepines: MOH Clinical practice guidelines 2/2008. [Last accessed on 2020 Dec 14]. Available from: https://www.moh.gov.sg/docs/librariesprovider4/guidelines/cpg_prescribing-of-benzodiazepines.pdf .
- 2.Goh LG. Administrative guidelines in insomnia. Singapore Fam Physician. 2010;36:15–8. [Google Scholar]
- 3.Chung KF, Lee CT, Yeung WF, Chan MS, Chung EW, Lin WL. Sleep hygiene education as a treatment of insomnia: A systematic review and meta-analysis. Fam Pract. 2018;35:365–75. doi: 10.1093/fampra/cmx122. [DOI] [PubMed] [Google Scholar]
- 4.Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: An update. World Psychiatry. 2019;18:337–52. doi: 10.1002/wps.20674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Schmitz A. Benzodiazepine use, misuse, and abuse: A review. Ment Health Clin. 2016;6:120–6. doi: 10.9740/mhc.2016.05.120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Trauer JM, Qian MY, Doyle JS, Rajaratnam, SMW, Cunnington D. Cognitive behavioural therapy for chronic insomnia: A systematic review and meta-analysis. Ann Intern Med. 2015;163:191–204. doi: 10.7326/M14-2841. [DOI] [PubMed] [Google Scholar]