Insomnia or Sleeplessness with the effects caused by its inception look seemingly harmless but has a deep impact on the subject’s life. Defined as disturbances in the circadian rhythms of sleep, the impacts of the problem are gradually being noticed worldwide. Mental health disorders, stress, irregular sleep schedules with poor sleeping habits are some of the chief causes of the problem. The incidence of the pandemic since 2020 has further shown to acerbate the issue.
What do statistics say?
Globally different studies have revealed about 10%-30% of adults have Insomnia at any given point in time, while 50-60% suffer from it yearly. The situation in the U.K. is no different. A 2021 survey in the U.K. has shown around 36% of U.K. adults struggle to get sleep on a weekly basis. 1 in 5 people in the U.K. has trouble falling asleep every night, while 50% of the U.K. population has trouble falling asleep once a month. Gender and age-specific studies have further shown that people aged between 45 and 54 struggle the most with the issue, while 55% of young people suffer from the problem on a monthly basis.
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Impact of Insomnia
A disturbed night’s sleep on a regular basis can gradually result in the above-mentioned symptoms and in turn, impact the individual’s social, and personal with professional interactions. If left untreated, this can result in further aggravation of pre-existing systemic conditions and pose serious health issues. The impact of Insomnia can even bring out depressive tendencies and pose life risks because of abnormal behaviour or suicidal thoughts. The U.K. specifically has reported an annual loss of £30bn because of insomnia tendencies among the working population. Night shift workers or those covering graveyard shifts have been seen to suffer the most.
Treatment exists in the form of medications, therapy or working on the factors leading to Insomnia. Out of all treatment options, medications are most important because they provide quicker results in a visible manner along with enabling the subject to lead a normal life. Antidepressants and Benzodiazepines are usually the most common treatment options for Insomnia that are largely preferred for their effectiveness and quick onset of action. Out of these options, benzos are more preferred owing to their effect on improving sleep quality and efficiency without increasing the risk of addiction potential. Out of all benzos, currently, Zopiclone is the most preferred Insomnia medication because of its improved efficiency and overall safety in the patients.
A word about Zopiclone
Zopiclone, available under the brand name Imovane, is a Cyclopyrrolone by nature. Cyclopyrrolones are a family of hypnotic and anxiolytic non-benzodiazepine drugs that though different, have pharmacological actions similar to those of benzodiazepines. Clinical studies have shown Zopiclone to be extremely effective in the treatment of short term insomnia with severe symptoms. Zopiclone, in the course of its action, for Insomnia, addresses difficulties in falling asleep, improves the overall quality of sleep and prevents nocturnal or early awakenings during sleep hours.
It is specifically advised by medical practitioners in cases of transient, situational or chronic Insomnia or Insomnia caused by systemic issues that are debilitating in nature and resulting in distress to the patient. Apart from these factors, Insomnia as a result of psychiatric disturbances is also a part of Zopiclone’s treatment indications. It is referred to as a Z-drug along with its two counterparts, Zaleplon and Zolpidem. Moreover, it has been in use for Insomnia since the 1980s.
How is it used in the treatment of Insomnia?
GABA receptors are amino acids that reduce neuronal excitability through the inhibition of nerve transmission. Zopiclone works on the sleep cycles of the human system through allosteric modulation of the GABA receptors. In order to repair the circadian rhythms and restore normal sleep schedules, Zopiclone displaces the binding of 3-H Flunitrazepam (A GABAA agonist) and enhances the binding of 35-S TBPS channel blocker (A GABA antagonist). This results in an enhancement of the inhibitory actions of GABA and produces the required anxiolytic and hypnotic effects.
Unlike traditional benzos, Zopiclone does not distinguish between GABA receptors containing different alpha subunits. This reduces the risk of addiction potential to a considerable extent and makes Zopiclone a safer alternative for use.
Zopiclone is a short-acting hypnotic
Zopiclone is licensed in the U.K. for adults with a bedtime dose of 7.5mg once daily for upto four weeks and is available under the brand name Imovane. It is prescribed for short term use to maintain the effectiveness of the drug and prevent the body from getting used to it. Of the four stages of sleep, Zopiclone prolongs the N2 and N3 stages of sleep with working on the REM stage additionally for a peaceful phase of undisturbed slumber. The SPC (Summary of Product Characteristics) approved by NICE (National Institute for Health and Care Excellence), U.K., has stated that duration of Zopiclone treatment should be 2-5 days for transient Insomnia that can be extended only upto 2-3 weeks for short term insomnia strictly discontinued after the time- interval.
Zopiclone Prescription Statistics
Statistics have shown Zopiclone to be a much more commonly prescribed treatment for Insomnia than Melatonin and other sleep medications. Even with increased prescriptions for Melatonin between 2014-2019, the popularity of Zopiclone is still on the higher side.
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A study was conducted on transport aircrews to assess the suitability of both Zopiclone and Melatonin as pharmacologic aids to facilitate crew rest. A total of 13 subjects were selected for a survey with a double-blind cross over protocol. These candidates were evaluated for psychomotor performance during three drug conditions; Placebo, 10mg Melatonin and 7.5 mg Zopiclone separated by 1-week intervals. The psychomotor performance of these subjects was assessed both pre and post-sleep. Both Zopiclone and Melatonin improved sleep relative to placebo. But Zopiclone had a slightly improved time (373.3 min) in comparison to Melatonin (370.2 min).
A number of theories have been suggested regarding the popularity of Zopiclone in comparison to Melatonin and other benzos or Z-drugs. One of these postulates is that sleep-promoting mechanisms in the human body are associated with a decline in body temperature. Zopiclone had been found to cause increased heat loss without any associated cardiac effects in comparison to Melatonin. That and the additional anxiolytic effects associated with the hypnotic functions add to its popularity.
Like both sides of a coin, the improved effects of Zopiclone in the treatment of Insomnia have also resulted in its increased misuse over the years.
Misuse of the drug
In a study conducted to evaluate the incidence of benzodiazepines and Z-drug misuse in the U.K., 1500 subjects were subjected to a questionnaire-based survey. Subjects from the age group 16-59 years were included in the subject category. Raw data was transferred in the form of a unique anonymised personal identifier.
A total of 392 (26.1%) of the subjects reported of ever using benzo or Z-drug. Of these, 116 ( 29.6%) admitted to misusing it. Thirty-four subjects ( 29.6%) out of the 116 had both used appropriately and misused the drug. While most of the subjects had misused only one of the drugs, 40.5% of individuals had misused at least two drugs. Zopiclone was among the frequently misused drugs, partly to help sleep and partly due to stress /addiction/social reasons related factors. 55.2% of the individuals obtained the prescription from a health professional, while 39.7% procured them online. The study provided an insight into the addiction potential of the drug with problems associated with its comparatively easy availability.
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The legal status of Zopiclone in the U.K.
Zopiclone is legally approved for use in the U.K. but as a controlled substance. Zopiclone is listed as a Schedule IV medication, and its procurement and use are being strictly regulated by the government. You are advised this medication only for cases of severe Insomnia, not responding satisfactorily to other medications. Even then, they are prescribed through the following protocols
- the practitioner advises the lowest dose that has an effect
- it is prescribed for the shortest time possible
- In elderly people/geriatric populations, Zopiclone is advised ahead of other sleep medications as its side effects wear off in a short time period.
Additionally, you have not prescribed Zopiclone or any other Z drug in cases of
- severe liver and kidney problems
- advanced myasthenia gravis (a neurological condition)
- sleep apnea-a condition resulting involuntary closing of throat muscles during sleep
- severe lung disease or ongoing breathing problems
Other precautions
The ongoing use of Zopiclone may come with minor side effects such as dizziness, lightheadedness and a metallic taste in the mouth. These side-effects can be exacerbated due to allergic reactions, overuse or drug interactions resulting in amnesia, hallucinations, bipolar disorder, depression and other serious complications.
In order to stay safe, it is important to follow the following precautions.
- -Avoid using them or use them with utmost precautions if you are pregnant or breastfeeding.
- Additionally, be very careful using them if you have a previous history of alcohol/drug abuse or are on meds for other psychological disorders.
- Avoid taking them with alcohol.
- Use them on an empty stomach and avoid a second dose in one night.
References:
- https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1440_may_31.pdf&ved=2ahUKEwjBzei1sbT3AhWQUGwGHRYQANEQFnoECAgQBg&usg=AOvVaw0md1WHpkunhkDRKIe5NC6H
- https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/sleeping-pills/
- https://www.formulatehealth.com/blog/insomnia-statistics-uk-how-many-people-have-sleep-problems
- https://www.sleepfoundation.org/insomnia/what-causes-insomnia
- https://emc-prod-wa.azurewebsites.net/emc/product/4060/smpc#gref
- https://pubmed.ncbi.nlm.nih.gov/7824046/
- https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/misuse-of-benzodiazepines-and-zdrugs-in-the-uk/82D4C6507C3DC2444CF0192959F4D43E
- https://www.linenbundle.com/blogs/news/insomnia-statistics
- https://www.epistemonikos.org/documents/d33f8d2b20fa1497c813e837e229b2338347b46e/
- https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/sleeping-pills/
- https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.nice.org.uk/guidance/ta77/resources/guidance-on-the-use-of-zaleplon-zolpidem-and-zopiclone-for-the-shortterm-management-of-insomnia-pdf-2294763557317&ved=2ahUKEwjas_iH9rX3AhUPR2wGHQZIAP0QFnoECBIQAQ&usg=AOvVaw2tWldwnUzqom_9xAbis4OW
