Exploration of prescribing patterns of benzodiazepine and non-benzodiazepine (Zdrugs) medications in the management of primary insomnia in adults in Saudi Arabia

Abstract

Background: Despite the increasing use of benzodiazepines and Z-drugs for insomnia, there are no guidelines for their use nor data on prescribing patterns in the Kingdom of Saudi Arabia (KSA). Aim: To explore the prescribing practices for treating insomnia in the KSA and begin the development of national guidelines, taking into account patients’ perspectives. Method: A mixed methods design was used in four phases. First, a retrospective audit of patients prescribed benzodiazepines or Z-drugs for insomnia (April 2012–March 2017) in King Fahad Central Hospital, Jazan, KSA, based on two US guidelines, was performed. Descriptive statistics, using Stata, were used to report findings. Second, a qualitative study, using NVivo, of physicians’ knowledge, perceptions and attitudes regarding treating primary insomnia and using US guidelines was performed. Third, an e-Delphi technique was used for guideline development. Twenty-seven insomnia experts participated in developing the consensus (≥ 80% agreement) around future national guidelines. Fourth, a cross-sectional survey (unrestricted, self-selected online survey) was utilised to explore patients’ knowledge, experiences and perceptions about using hypnotics to manage primary insomnia in the KSA. The data were encoded and analysed using Stata. Results: Of the 504 records reviewed, 379 patients (75%) were prescribed benzodiazepines or Z-drugs; only 182 (48%) had documented diagnoses. Of the 307 patients (60%) diagnosed with insomnia, none received cognitive behavioural therapy for insomnia (CBT-I). No patients were reviewed by physicians for long-term use. No records met all criteria. Physicians’ perceptions and attitudes in KSA toward using US or other international guidelines were based on knowledge, resistance and the presence of barriers and facilitators. In the Delphi study, sixteen 4 statements achieved the consensus to be included in future KSA guidelines. The survey study revealed that patients have limited knowledge of insomnia and its treatment. Patients are often prescribed hypnotics for insomnia, do not receive CBT-I as first-line treatment, and are rarely involved in treatment decisions. Most patients are on long-term hypnotics use and are not reviewed regularly by their doctors or provided with a plan for discontinuation. There is considerable resistance among patients to using nonpharmacological treatment options for insomnia. Conclusion: The Ministry of Health should enhance public awareness of insomnia, provide training for physicians on prescribing hypnotics and CBT-I, improve hospital administration and encourage documentation. The produced consensus statements can be used, taking into consideration patients’ perspectives, in the development of national guidelines that will standardise the use of benzodiazepines and Z-drugs for the treatment of primary insomnia in adults in the KSA.