Editing Benzodiazepine (section)

===Insomnia===
{{Further|Insomnia}}
[[File:Normison.jpg|thumb|[[Temazepam]] (Normison) 10 mg tablets]]
Benzodiazepines can be useful for short-term treatment of [[insomnia]]. Their use beyond 2 to 4 weeks is not recommended due to the risk of dependence. The Committee on Safety of Medicines report recommended that where long-term use of benzodiazepines for insomnia is indicated then treatment should be intermittent wherever possible.<ref>{{cite web|url= http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con2024428.pdf|archive-url= http://webarchive.nationalarchives.gov.uk/20141206140040/http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources/con2024428.pdf|url-status= dead|archive-date= 6 December 2014|title= Current problems|date= 1988|website= www.mhra.gov.uk|access-date= 21 March 2020}}</ref> It is preferred that benzodiazepines be taken intermittently and at the lowest effective dose. They improve sleep-related problems by shortening the time spent in bed before falling asleep, prolonging the sleep time, and, in general, reducing wakefulness.<ref name="nice-hypnotics">{{cite web|title=Technology Appraisal Guidance 77. Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia |url=http://www.nice.org.uk/nicemedia/pdf/TA077fullguidance.pdf |publisher=National Institute for Clinical Excellence |date=April 2004 |access-date=26 July 2009 |url-status=dead |archive-url=https://web.archive.org/web/20081203063917/http://www.nice.org.uk/nicemedia/pdf/TA077fullguidance.pdf |archive-date=3 December 2008 }}</ref><ref name="pmid17853625">{{cite journal | vauthors = Ramakrishnan K, Scheid DC | title = Treatment options for insomnia | journal = American Family Physician | volume = 76 | issue = 4 | pages = 517–526 | date = August 2007 | pmid = 17853625 | url = http://www.aafp.org/afp/2007/0815/p517.html }}</ref> However, they worsen sleep quality by increasing light sleep and decreasing deep sleep. Other drawbacks of hypnotics, including benzodiazepines, are possible tolerance to their effects, [[rebound insomnia]], and reduced slow-wave sleep and a withdrawal period typified by rebound insomnia and a prolonged period of anxiety and agitation.<ref name="handbook_of_integrative">{{cite book | vauthors = Carlstedt RA | title = Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine: Perspectives, Practices, and Research | date = 13 December 2009 | publisher = Springer Publishing Company | url = https://books.google.com/books?id=4Tkdm1vRFbUC | isbn = 978-0-8261-1094-7 | pages = 128–130 }}</ref><ref name="ahrq"/>

The list of benzodiazepines approved for the treatment of insomnia is fairly similar among most countries, but which benzodiazepines are officially designated as first-line hypnotics prescribed for the treatment of insomnia varies between countries.<ref name="pmid17853625"/> Longer-acting benzodiazepines such as [[nitrazepam]] and [[diazepam]] have residual effects that may persist into the next day and are, in general, not recommended.<ref name="nice-hypnotics"/>

Since the release of [[nonbenzodiazepines]], also known as z-drugs, in 1992 in response to safety concerns, individuals with insomnia and other sleep disorders have increasingly been prescribed nonbenzodiazepines (2.3% in 1993 to 13.7% of Americans in 2010), less often prescribed benzodiazepines (23.5% in 1993 to 10.8% in 2010).<ref name="Kaufmann_2016">{{cite journal | vauthors = Kaufmann CN, Spira AP, Alexander GC, Rutkow L, Mojtabai R | title = Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010 | journal = Pharmacoepidemiology and Drug Safety | volume = 25 | issue = 6 | pages = 637–645 | date = June 2016 | pmid = 26711081 | pmc = 4889508 | doi = 10.1002/pds.3951 }}</ref><ref>{{cite web|url=http://www.accessdata.fda.gov/drugsatfda_docs/nda/pre96/019908_S000_AP&AE_LTRS&FPL.pdf |archive-url=https://ghostarchive.org/archive/20221009/http://www.accessdata.fda.gov/drugsatfda_docs/nda/pre96/019908_S000_AP&AE_LTRS&FPL.pdf |archive-date=9 October 2022 |url-status=live|title=Approval letter for Ambien|website=Food and Drug Administration}}</ref> It is not clear as to whether the new [[nonbenzodiazepine|non benzodiazepine]] hypnotics (Z-drugs) are better than the short-acting benzodiazepines. The efficacy of these two groups of medications is similar.<ref name="nice-hypnotics"/><ref name="ahrq"/> According to the US [[Agency for Healthcare Research and Quality]], indirect comparison indicates that side-effects from benzodiazepines may be about twice as frequent as from nonbenzodiazepines.<ref name="ahrq">{{cite web |vauthors=Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M |title=Manifestations and Management of Chronic Insomnia in Adults. Summary, Evidence Report/Technology Assessment: Number 125 | publisher = Agency for Healthcare Research and Quality |date=June 2005 |url=http://www.ahrq.gov/clinic/epcsums/insomnsum.pdf |archive-url=https://ghostarchive.org/archive/20221009/http://www.ahrq.gov/clinic/epcsums/insomnsum.pdf |archive-date=9 October 2022 |url-status=live }}</ref> Some experts suggest using nonbenzodiazepines preferentially as a first-line long-term treatment of insomnia.<ref name="pmid17853625"/> However, the UK [[National Institute for Health and Clinical Excellence]] did not find any convincing evidence in favor of Z-drugs. NICE review pointed out that short-acting Z-drugs were inappropriately compared in clinical trials with long-acting benzodiazepines. There have been no trials comparing short-acting Z-drugs with appropriate doses of short-acting benzodiazepines. Based on this, NICE recommended choosing the hypnotic based on cost and the patient's preference.<ref name="nice-hypnotics"/>

Older adults should not use benzodiazepines to treat insomnia unless other treatments have failed.<ref name="AGSfive"/> When benzodiazepines are used, patients, their caretakers, and their physician should discuss the increased risk of harms, including evidence that shows twice the incidence of [[traffic collisions]] among driving patients, and falls and hip fracture for older patients.<ref name="AGSfive">{{cite journal |author1 = American Geriatrics Society |author1-link = American Geriatrics Society |title = Five Things Physicians and Patients Should Question |journal = Choosing Wisely: An Initiative of the ABIM Foundation |url = http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/ |access-date = 1 August 2013 |archive-date = 1 September 2013 |archive-url = https://web.archive.org/web/20130901100140/http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/ |url-status = dead }}, which cites</ref><ref name="pmid16156679"/><ref>{{cite journal | publisher = American Geriatrics Society 2012 Beers Criteria Update Expert Panel | title = American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults | journal = Journal of the American Geriatrics Society | volume = 60 | issue = 4 | pages = 616–631 | date = April 2012 | pmid = 22376048 | pmc = 3571677 | doi = 10.1111/j.1532-5415.2012.03923.x | vauthors = Fick D, Semla T, Beizer J, Brandt N, Dombrowski R, DuBeau CE, Flanagan N, Hanlon J, Hollmann P, Linnebur S, Nau D, Rehm B, Sandhu S, Steinman M | collaboration = American Geriatrics Society 2012 Beers Criteria Update Expert Panel }}</ref>