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Br J Gen Pract. 2006 December 1; 56(533): 964–967.
PMCID: PMC1934058

GPs' attitudes to benzodiazepine and ‘Z-drug’ prescribing: a barrier to implementation of evidence and guidance on hypnotics

A Niroshan Siriwardena, MMedSci, PhD, FRCGP, Visiting Professor, GP
School of Health and Social Care, University of Lincoln, Lincoln
Zubair Qureshi, MRCGP, GP
South Park Surgery, Lincoln
Steve Gibson, BPharm, MPharm, Pharmaceutical Adviser, Sarah Collier, Research Assistant, and Martin Latham, FRCGP, GP


Zaleplon, zolpidem, and zopiclone (‘Z-drugs’) prescribing is gradually rising in the UK, while that of benzodiazepine hypnotics is falling. This situation is contrary to current evidence and guidance on hypnotic prescribing. The aim of this study was to determine and compare primary care physicians' perceptions of benefits and risks of benzodiazepine and Z-drug use, and physicians' prescribing behaviour in relation to hypnotics using a cross-sectional survey. In 2005 a self-administered postal questionnaire was sent to all GPs in West Lincolnshire Primary Care Trust. The questionnaire investigated perceptions of benefits and disadvantages of benzodiazepines and Z-drugs. Of the 107 questionnaires sent to GPs, 84 (78.5%) analysable responses were received. Responders believed that Z-drugs were more effective than benzodiazepines in terms of patients feeling rested on waking (P<0.001), daytime functioning (P<0.001), and total sleep time (P = 0.03). Z-drugs were also thought to be safer in terms of tolerance (P<0.001), addiction (P<0.001), dependence (P<0.001), daytime sleepiness (P<0.001), and road traffic accidents (P = 0.018), and were thought to be safer for older people (P<0.001). There were significant differences between GPs' perceptions of the relative benefits and risk of Z-drugs compared with benzodiazepines. The majority of practitioners attributed greater efficacy and lower side effects to Z-drugs. GPs' beliefs about effectiveness and safety are not determined by current evidence or national (NICE) guidance which may explain the increase in Z-drug prescribing relative to benzodiazepine prescribing.

Keywords: attitude, cross sectional studies, hypnotics and sedatives, physicians' practice patterns, prescriptions


Most hypnotic prescribing takes place in primary care, and the use and cost of these drugs is rising. There are large variations in hypnotic prescribing,1 with some areas of the UK having higher levels of benzodiazepine and ‘Z-drug’ prescribing (hypnotics including zopiclone, zolpidem, and zaleplon) compared with national data.

There are potential side effects of hypnotic drugs, evidence of long-term use contrary to licensed indications, and lack of evidence distinguishing short-acting benzodiazepine and newer Z-drug hypnotics.2,3 The National Service Framework for Mental Health4 and the National Institute for Health and Clinical Excellence (NICE) in the UK5 advised monitoring of hypnotic prescribing and a cost-minimisation approach that would tend to favour short-acting benzodiazepine hypnotic use.

Despite NICE guidance, benzodiazepine prescribing rates have continued to fall over the past decade, and there has been a corresponding rise in the use of newer hypnotic drugs for insomnia over the same period.3 Although there has been considerable research into the attitudes of patients,69 doctors,1012 and both13,14 regarding the use of benzodiazepines, there is limited published research on patients' and practitioners' perceptions of Z-drugs.

The aim of this study was to investigate and compare GPs' perceptions of benefits and risks of benzodiazepines and Z-drugs in one large primary care trust. This study was part of a larger study investigating the reasons for variations in hypnotic prescribing and exploring methods for reducing this in a primary care trust.


West Lincolnshire Primary Care Trust has 40 general practices serving 214 000 patients. Prescribing of hypnotics is an important quality issue for all primary care organisations. Previous attempts to address prescribing in this area met with resistance to change. To address this the authors decided to explore practitioners' beliefs about hypnotic prescribing. A survey instrument, based on a search of the literature and an adaptation of a previously published instrument, was developed to collect data.13

In 2005 a self-administered postal questionnaire was sent to all GPs on the principal (independent practitioner) list of West Lincolnshire Primary Care Trust. The questionnaire focused on practitioners' perceptions of benefits and disadvantages of benzodiazepines and Z-drugs, and preferences for management of insomnia and anxiety. The questionnaire was developed using information from a review of the literature, discussion within the project steering group, and reference to experts in the field.

Returned questionnaires were entered into a spreadsheet according to a predetermined coding frame. Data were analysed using SPSS (version 12.1). Wilcoxon's signed ranking test was used for comparison of groups.


Of the 107 GPs who were sent questionnaires, 84 (78.5%) responded after one reminder. Characteristics of these GPs are described in Table 1.

Table 1
Demographic data of GPs.

How this fits in

The prescribing of Z-drugs continues to rise but that of benzodiazepines is falling. Whereas there has been research on doctors' perceptions of benzodiazepines, little is known about perceptions of Z-drugs or the drugs relative to each other. This study demonstrates that GPs believe that Z-drugs are more effective and safer than benzodiazepines despite published evidence and guidelines to the contrary. This is a potential barrier to implementation of national guidance on hypnotics.

Responders perceived that Z-drugs were more effective in terms of patients feeling rested on waking, daytime functioning, and total sleep time, and that they were less likely to lead to side effects, particularly tolerance, addiction, dependence, daytime sleepiness, and road traffic collisions. Z-drugs were also believed to be safer for older patients (Table 2).

Table 2
GPs' perceptions of benefits and disadvantages of benzodiazepines and ‘Z-drugs’.


This was a study investigating prescribing preferences in a single primary care trust. The response rate from GP principals (independent practitioners) was high, adding to the validity of the findings in relation to local prescribing of these drugs. Although caution needs to be taken in generalising the results to other primary care organisations, the results are consistent with national changes in hypnotic prescribing.

There were significant differences between GPs perceptions of the relative benefits and risk of Z-drugs compared with benzodiazepines, with the majority of practitioners attributing greater efficacy and lower side effects to Z-drugs.

Practitioners' beliefs about relative indications, effectiveness, and safety are not determined by current evidence or national (NICE) guidance. Beliefs about evidence can prevent implementation of national guidance. The attitudes of GP responders in favour of Z-drugs help to explain the increase in prescribing of Z-drugs relative to that of benzodiazepines, a national phenomenon that is inconsistent with NICE guidance.

Despite GPs' positive attitudes to guidelines overall,15 NICE guidance continues to be variable in its implementation.16 Guidance has led to changes in prescribing of some drugs, and has been supported when it is consistent with previous practice.17 There is limited research into the effect of guidance based on new evidence that discourages past patterns of behaviour, as in this study which examined increasing use of Zdrug hypnotics. A number of factors have been identified as influencing adherence to prescribing guidance in general practice including relative safety, efficacy, practicability, and information conflicting with guidance, most importantly from the pharmaceutical industry.18

The targeted use of commercial techniques19 and meetings supported by pharmaceutical companies20 to proffer selected positive information about products early in their marketing, affects the attitudes of doctors and their prescribing behaviour.2123 Despite professional concerns about the credibility of such information24 and the perceived immunity of some doctors to commercial influence,25 practitioners26 and their patients27 know that prescribing is being unduly influenced.

A number of approaches could be used to implement the NICE guidance and reverse current non-evidencebased trends in relation to hypnotic prescribing. Options include delivering a clearer message related to outcomes, communicating effectively using opinion leaders and other evidenced techniques, and enabling doctors and patients to understand the true relative advantages, disadvantages, and consequences of using these drugs28 and of non-pharmacological treatments. A clearer structural context is needed in health trusts supportive of implementation.17 Further research should investigate the relationship between prescribers' attitudes and actual prescribing, and examine how to change attitudes and behaviour to improve performance. GPs need to be aware of and discuss these beliefs in the context of available evidence to make informed and collaborative decisions about their prescribing practices for insomnia.


We thank GPs, the board and executive of West Lincolnshire Primary Care Trust for supporting this study. We are grateful to Dr Ross Upshur who provided a copy of his questionnaire developed for another study, and to Professor Anthony Avery, Dr Hugh Middleton, and Dr Michael Dewey for comments on earlier drafts.


Funding body

This study was funded with a Research Capacity Development Award from Trent Research and Development Support Unit and additional support from West Lincolnshire Primary Care Trust

Ethics committee

Approval was granted by Lincolnshire Research Ethics Committee Q4/Q2405/49 and research governance approval by West Lincolnshire Primary Care Trust

Competing interests

The authors have stated that there are none


1. Baker RH, Tait C, Fraser RC. Use of benzodiazepines. BMJ. 1994;309(6951):412. [PMC free article] [PubMed]
2. Dundar Y, Dodd S, Strobl J, et al. Comparative efficacy of newer hypnotic drugs for the short-term management of insomnia: a systematic review and meta-analysis. Hum Psychopharmacol. 2004;19(5):305–322. [PubMed]
3. Dundar Y, Boland A, Strobl J, et al. Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation. Health Technol Assess. 2004;8(24):1–125.
4. Department of Health. National Service Framework for mental health: modern standards and service models. London: Department of Health; 2003.
5. National Institute for Health and Clinical Excellence. Guidance on the use of zaleplon, zolpidem and zopiclone for the short term management of insomnia. London: NICE; 2004. Technology Appraisal Guidance 77.
6. Barnas C, Fleischhacker WW, Whitworth AB, et al. Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers. Psychopharmacology (Berl) 1991;103:233–239. [PubMed]
7. King MB, Gabe J, Williams P, Rodrigo EK. Long term use of benzodiazepines: the views of patients. Br J Gen Pract. 1990;40:194–196. [PMC free article] [PubMed]
8. Lyndon RW, Russell JD. Benzodiazepine use in a rural general practice population. Aust N Z J Psychiatry. 1988;22(3):293–298. [PubMed]
9. Nolan L, O'Malley K. Patients, prescribing, and benzodiazepines. Eur J Clin Pharmacol. 1988;35(3):225–229. [PubMed]
10. Bjorner T, Laerum E. Factors associated with high prescribing of benzodiazepines and minor opiates. A survey among general practitioners in Norway. Scand J Prim Health Care. 2003;21(2):115–120. [PubMed]
11. Matthews K, Eagles JM, Matthews CA. The use of antidepressant drugs in general practice. A questionnaire survey. Eur J Clin Pharmacol. 1993;45:205–210. [PubMed]
12. Hamilton IJ, Reay LM, Sullivan FM. A survey of general practitioners' attitudes to benzodiazepine overprescribing. Health Bull (Edinb) 1990;48:299–303. [PubMed]
13. Mah L, Upshur RE. Long term benzodiazepine use for insomnia in patients over the age of 60: discordance of patient and physician perceptions. BMC Fam Pract. 2002;3:9. [PMC free article] [PubMed]
14. Iliffe S, Curran HV, Collins R, et al. Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers. Aging Ment Health. 2004;8(3):242–248. [PubMed]
15. Siriwardena AN. Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour. Br J Gen Pract. 1995;45:643–647. [PMC free article] [PubMed]
16. Rawlins MD. 5 NICE years. Lancet. 2005;365:904–908. [PubMed]
17. Sheldon TA, Cullum N, Dawson D, et al. What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews. BMJ. 2004;329:999. [PMC free article] [PubMed]
18. Wathen B, Dean T. An evaluation of the impact of NICE guidance on GP prescribing. Br J Gen Pract. 2004;54:103–107. [PMC free article] [PubMed]
19. Roughead EE, Harvey KJ, Gilbert AL. Commercial detailing techniques used by pharmaceutical representatives to influence prescribing. Aust N Z J Med. 1998;28(3):306–310. [PubMed]
20. Carney SL, Nair KR, Sales MA, Walsh J. Pharmaceutical industrysponsored meetings: good value or just a free meal? Intern Med J. 2001;31(8):446–447. [PubMed]
21. Lexchin J. What information do physicians receive from pharmaceutical representatives? Can Fam Physician. 1997;43:941–945. [PMC free article] [PubMed]
22. Waldron I. Increased prescribing of Valium, Librium, and other drugs — an example of the influence of economic and social factors on the practice of medicine. Int J Health Serv. 1977;7(1):37–62. [PubMed]
23. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283(3):373–380. [PubMed]
24. Tracy CS, Dantas GC, Upshur RE. Evidence-based medicine in primary care: qualitative study of family physicians. BMC Fam Pract. 2003;4:6. [PMC free article] [PubMed]
25. Hodges B. Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns and clerks. CMAJ. 1995;153(5):553–559. [PMC free article] [PubMed]
26. Lexchin J. Interactions between physicians and the pharmaceutical industry: what does the literature say? CMAJ. 1993;149:1401–1407. [PMC free article] [PubMed]
27. Gibbons RV, Landry FJ, Blouch DL, et al. A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998;13:151–154. [PMC free article] [PubMed]
28. Rogers EM. Diffusion of innovations. New York, London: Free Press; 1995. pp. 1–38.

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