Benzodiazepines and Z-Drugs
Professional Standards Regarding Benzodiazepines and Z-Drugs
The standard establishes the professional, ethical and practice requirements for physicians in relation to prescribing benzodiazepines and Z-drugs in outpatient community settings. The standard does not address prescribing for palliative or end-of-life patients, acute seizure disorders, akathisia, and alcohol withdrawal.
Benzodiazepines are gamma-aminobutyric acid (GABA) receptor agonists that have hypnotic, anxiolytic, muscle relaxant and anti-convulsant properties. Benzodiazepines are commonly divided into three groups depending on how quickly they are eliminated from the body:
- Short acting – half-life: less than 12 hours such as midazolam and triazolam.
- Intermediate acting – half-life: between 12-24 hours such as alprazolam, lorazepam and temazepam.
- Long acting – half-life: greater than 24 hours such as diazepam, clonazepam, clorazepate and flurazepam.
Benzodiazepines are monitored by the Nova Scotia Prescription Monitoring Program (NSPMP).
Z-Drugs are non-benzodiazepine and hypnotic drugs of the imidazopyridine class. They are GABA receptor agonists but because they have a different structure, they produce fewer anxiolytic and anticonvulsant effects than benzodiazepines. The Z-drugs are typically prescribed for insomnia and include zaleplon, zolpidem and zopiclone. The Z -drugs tend to be quicker acting and have shorter half-lives than the benzodiazepines. They are not “safer” than benzodiazepines as they carry the same risks of physiological dependence and protracted withdrawal as benzodiazepines. The only Z-drug currently monitored by the Nova Scotia Prescription Monitoring Program (NSPMP) is Zolpidem through the Controlled Drugs and Substance Act, Schedule IV.
- Before initiating treatment with benzodiazepine or Z-drugs, physicians must:
- When initiating treatment of patients with benzodiazepines or Z-drugs, physicians must:
- When managing patients being treated with benzodiazepines and Z-drugs, including but not limited to those patients on long-term therapy, physicians must:
- With respect to tapering patients on benzodiazepines and Z-drugs, physicians must:
Additional Consideration for Older Patients
Senior patients have an increased sensitivity to benzodiazepines and decreased metabolism of long-acting medications. New starts of benzodiazepines and Z-drugs for patients over 65 must:
- be implemented with extreme caution and not used as first choice for insomnia, agitation, delirium or for managing behaviors arising from dementia;
- take into consideration declining renal, hepatic and cognitive function and polypharmacy in older patients;
- include discussion and documentation of additional risks more common in this age group including falls, impaired motor skills and coordination, postural instability, confusion, drowsiness and possible negative effects on cognition and memory; and
- monitor and reevaluate the use and effectiveness of the medications regularly.
It’s not uncommon for primary care physicians to take over the care of patients maintained on unusual medication regimes, including benzodiazepines and Z-drugs. This standard should be read concurrently with the College’s Professional Standards and Guidelines Regarding Caring for Legacy Patients.
College of Physicians and Surgeons of Nova Scotia
- Professional Standards and Guidelines Regarding Informed Patient Consent to Treatment
- Professional Standard Initiation of Opioid Therapy for Acute Pain
- Professional Standard and Guidelines Regarding Prescribing
- Professional Standards and Guidelines Regarding Caring for Legacy Patients
Canadian Medical Protective Association
The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain
BZRA Deprescribing Algorithm 2019
The development of this College standard was informed by the College of Physicians and Surgeons of Manitoba’s Standard of Practice Prescribing Benzodiazepines & Z-Drugs.
First Approved by the Council of the College of Physicians and Surgeons of Nova Scotia on: March 25, 2022
Date of next review: 2025