Screening and assessment of disorders of benzodiazepine, zolpidem and zopiclone use

Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about medication use, as part of a general screen for disorders of substance use and gambling; these disorders are common (and often co-exist) and people are reluctant to disclose them, often due to fear of stigma. Screening and assessment of substance use and addictive behaviours outlines history-taking (including use of the ASSIST-Lite tool), examination, and investigations that should be considered in a broad review of substance use and addictive behaviour.

An additional approach that is beneficial in addressing benzodiazepine use is to identify patients prescribed benzodiazepines by searching practice records, and sending them a tailored letter that encourages reductionDarker, 2015. A template ‘Practice letter to patients about benzodiazepine reduction’ is available from the Royal Australasian College of General Practitioners (RACGP) website, which also includes a fact sheet for patients. Sample responses to requests for benzodiazepines are also available from the RACGP website.

In discussing benzodiazepine, zolpidem and zopiclone use, ask about trends in use, including any past efforts to reduce, withdrawal symptoms, reasons for starting and continuing (eg anxiety or sleep disorders) and potential harms, including risk of overdose and child protection concerns.

Withdrawal symptoms include anxiety, insomnia, irritability, tremor, palpitations, poor concentration, distorted perception and hyperacusisSchifano, 2019. Signs of withdrawal include tachycardia, hypertension and myoclonic twitches. Abrupt discontinuation may be accompanied by seizures, particularly in patients taking higher doses for prolonged periods and those with a history of seizures. Delirium may also occur on abrupt discontinuation.

Withdrawal symptoms typically emerge within 1 to 5 days of stopping, peak around 7 days and usually abate over the next 2 to 3 weeks. Symptoms of anxiety and insomnia may persist for months after stopping. Withdrawal symptoms may emerge and abate earlier with use of short half-life benzodiazepines. More severe withdrawal may be seen with prolonged higher-dose use.

To quantify use of benzodiazepines, zolpidem or zopiclone, calculate the approximate oral daily diazepam equivalent for each drug using Oral dose equivalents of benzodiazepines, zolpidem and zopiclone. If several different drugs are being used concurrently, sum the diazepam equivalents. This will provide an estimate of the dose of diazepam on which the patient may be stabilised. Widely varying half-lives and receptor-binding characteristics make exact dose equivalents difficult to establish; a range incorporating values 50% above and below the estimates in Oral dose equivalents of benzodiazepines, zolpidem and zopiclone is reasonable. Patients sometimes overestimate their consumption; seek corroboration of the doses they are being prescribed using real-time prescription monitoring, although this will not identify any drugs acquired illicitly. Observation in hospital can help assess a patient’s tolerance by establishing whether they require their stated dose to avoid withdrawal. If the oral daily diazepam equivalent exceeds 40 mg, seek specialist advice.

Table 1. Oral dose equivalents of benzodiazepines, zolpidem and zopiclone
Ashton, 2005 Busto, 1986 SA Health Sussex Partnership NHS Foundation Trust, 2017
This table is used to quantify total daily oral doses of benzodiazepines, zolpidem and zopiclone to estimate the equivalent dose of diazepam on which the patient should be stabilised; if several different drugs are being used concurrently, sum the diazepam equivalents. Exact dose equivalents are difficult to establish; a range incorporating values 50% above and below these estimates is reasonable.
Drug	Approximate dose equivalent to 10 mg of oral diazepam [NB1]
alprazolam	0.5 to 1 mg
bromazepam	6 mg
clobazam	20 mg
clonazepam	0.5 mg
diazepam	10 mg
flunitrazepam	1 to 2 mg
lorazepam	1 to 2 mg [NB2]
nitrazepam	10 mg
oxazepam	20 to 60 mg
temazepam	20 mg
zolpidem	20 mg
zopiclone	15 mg
Note: NB1: To calculate the oral daily diazepam equivalent for each drug, divide the daily dose by the approximate dose equivalent in this table and multiply by 10 mg. For example, if the patient is taking temazepam 40 mg daily, the calculation is: 40 mg divided by 20 mg multiplied by 10 mg = 20 mg oral daily diazepam equivalent. NB2: Lorazepam may be relatively more potent at higher doses.