Factors affecting clinical pharmacist decision-making when reviewing and prescribing z-drugs in primary care: a qualitative interview study

Background: Z-drugs (zopiclone, zolpidem and zaleplon) are drugs with dependence forming characteristics licensed for the short-term management of insomnia. Patients regularly prescribed z-drugs are candidates for ‘structured medication reviews’, routinely delivered by pharmacists employed in general practice or primary care networks in England. 

Aim: To understand the factors that affect pharmacist decision-making when reviewing and prescribing z-drugs in primary care. 

Method: Qualitative semi-structured interviews with general practice based pharmacists were conducted using MS Teams®. Clinical vignettes to simulate real-world practice were sent to participants and then discussed at interview, followed by structured interview questions. Interview transcripts were thematically analysed to identify themes and sub-themes expressed by participants. 

Results: Three over-arching themes emerged over the course of qualitative interviews with 10 clinical pharmacists: the perceived role of the pharmacist in deprescribing, the decision-making process, and perceptions of best practice. Pharmacists highlighted that relationships with patients were an important foundation for medication reviews regarding z-drugs and that at times they felt pressure to continue prescribing z-drugs beyond their licensed use. Participants explored rule-based reasoning and compassionate care when rationalising their decision-making for reviewing and prescribing z-drugs. 

Conclusion: Patient factors, time pressures, ‘rule-based’ beliefs and pharmacist self-efficacy were key practice aspects which can influence the pharmacist decision-making process when reviewing or prescribing z-drugs. Pharmacists believed z-drugs should be short-term interventions for insomnia, with non-pharmacological, holistic treatment being more appropriate for long term management.