17 Sep 2025 Improving your prescribing of zopiclone and trazodone for insomnia
The Therapeutics Initiative produced individual prescribing Portraits on the topic of improving how clinicians prescribe zopiclone and trazodone for insomnia (1 January 2022 to 31 December 2023). The Portraits were released online to clinicians in BC who are registered for the Portrait program. Eligible clinicians (primary care physicians and nurse practitioners) were randomized to have access to the Portrait in two groups, an early group of clinicians were granted online access to Portrait in January 2025 and a delayed group were granted access in September 2025.
This Portrait was accompanied by the Therapeutics Letter: Improving how we prescribe zopiclone and trazodone issue 158 (August-September 2025). 1
As of 2024, zopiclone and trazodone were the drugs most often prescribed for insomnia in BC. Often, this is for purposes not approved by Health Canada, or at doses exceeding a ceiling above which additional benefit is unlikely (see the associated Therapeutics Letter for a summary of the available evidence).
This Letter and Portrait aim to:
- Identify the lowest effective dose for a first prescription of zopiclone or trazodone;
- Suggest a strategy for patients already taking excessive doses to achieve the lowest effective dose; and
- Introduce or facilitate consistent use of non-pharmacological treatments (e.g., sleep restriction).2
Abbreviations used
ATC: Anatomical Therapeutic Chemical code assigned to medicine
BCN&M: British Columbia College of Nurses & Midwives
CPSBC: College of Physicians and Surgeons of British Columbia
FP: Family practitioner
FNHA: First Nations Health Authority
GP: General practice
ICD: International Classification of Diseases
MSP: Medical Services Plan
NP: Nurse practitioner
PSP: Practice Support Program
RCT: Randomized controlled trials
Data definitions
Who received this Portrait?
Clinicians who have registered online for a Portrait account and who meet all of the following criteria have access to an individual prescribing Portrait:
- General practice (GP) physicians or nurse practitioners (NP) registered to practise in British Columbia;
- Family practitioners (FP) registered by the BC Medical Services Plan and the College of Physicians and Surgeons of BC with an active practice, or physicians registered primarily as GP-emergency medicine and FP-emergency medicine physicians;
- NPs registered by the BC Medical Services Plan and the BC College of Nurses & Midwives with an active practice; and
- had ≥100 patients with any prescriptions filled at a community pharmacy in 2022-2023, according to PharmaCare and PharmaNet claims data; and
- have not opted out of the Portrait program.
How were patients assigned to this Portrait?
Patients were included in a clinician Portrait if they met all of the following criteria:
- filled at least one prescription for zopiclone or trazodone in a community pharmacy between 1 January 2022 and 31 December 2023;
- were aged 18 or older at time of first prescription of zopiclone or trazodone;
- were BC residents based on BC MSP enrolment at any time during the study period (2022/23);
- For trazodone only, patients were excluded if they had a diagnosis of major depression in their medical records from 1 January 2021 to 31 December 2023. Diagnosis of depression was defined as at least 1 MSP visit or 1 hospital visit with diagnostic code (ICD-9 = 296; ICD-10 = F32). The diagnosis could be by any practitioner, not necessary the primary care clinician.
- Data for patients who are federally insured (e.g., Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) were not available.
Clinicians may receive a Portrait with masked or missing elements if they prescribed fewer than 6 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-20 patients), and percentages were rounded to the nearest 5%.
What prescriptions were included in this Portrait?
Dispensing events of zopiclone and trazodone prescriptions were extracted from PharmaNet claims data and included all prescriptions dispensed at a community pharmacy in BC with a clinician’s prescribing number. Reversed prescription claims, out-of-province prescriptions, or drugs dispensed in hospital were not included.
Prescriptions included: zopiclone (ATC-N05CF01) and/or trazodone (ATC-N06AX05)
How was “optimal prescribers in BC” determined?
Based on the best available evidence, we identified the lowest effective dose for a first prescription of zopiclone or trazodone and compared that to “optimal prescribers in BC” defined as the top 15th percentile of family physicians and nurse practitioners who prescribed the evidence-based ceiling doses (or less), more often than did 85% of peers.
Evidence-based ceiling doses:
- Zopiclone: 5 mg/day for those 65 years and older
- Zopiclone: 7.5 mg/day for adults under 65 years
- Trazodone: 50 mg/day for adults under 65 years3
Please refer to Improving how we prescribe zopiclone and trazodone Therapeutics Letter, issue 158, 2025 August-September1 for a more detailed assessment of the evidence.
References and notes
- Therapeutics Initiative. Improving how we prescribe zopiclone and trazodone for insomnia. Therapeutics Letter, issue 158, 2025 August-September. https://www.ti.ubc.ca/2025/09/17/158-improving-how-we-prescribe-zopiclone-and-trazodone-for-insomnia/
- Non-pharmacological treatments such as sleep restriction and cognitive behavioural therapy for insomnia (CBT-i). See CBT-I resource: https://mysleepwell.ca/
- Trazodone is not indicated for insomnia; its use for insomnia outside of mood disorders is off-label.
Research component
The research objective is to determine the impact of the Portrait on clinician prescribing. This impact will be evaluated at an aggregated level over the coming year by comparing pooled prescribing data from clinicians in the early group to pooled prescribing data from clinicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and clinician numbers. No clinician or patient will be identified in any reports or publications. Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. Ethics approval for this evaluation will be obtained from the University of British Columbia Clinical Ethics Review Board. This evaluation is being led by Drs. Aaron M Tejani, Anshula Ambasta and Colin Dormuth, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.
If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca
FAQ
Can I request the names of my patients included in this Portrait?
No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list. However, other resources may be available for you. Contact your Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.
I have a unique/specialized practice and do not believe that my data should be compared to GPs. Shouldn’t my comparison cohort be other clinicians with practices similar to mine?
Our ability to accurately include clinicians depends on how each clinician is listed in the BC MSP data. For example, to be included in the program, a clinician must be defined as a Nurse Practitioner or a General Practitioner with a licence status of Private Practice in the MSP data; beyond that, it is difficult to accurately identify any individual’s specific work environment, as many clinicians work in multiple locations. We try to keep Portraits relevant to recipients by having a minimum prescribing criterion for each Portrait topic. Clinicians who prescribe no or very little of the drug in question typically will not receive a Portrait.
Creating accurate comparison cohorts is difficult for the same reasons. We often include the BC median as a points of interest when it is feasible, but we know that many clinicians have unique or specialized practices and this comparator is not ideal. Hopefully, as we continue to build and refine the Portrait program, we will be able to provide comparisons that are more relevant to a variety of practices.
Portraits are really intended to be a tool for you to reflect upon and consider your own prescribing. Rest assured that we are not directly comparing your prescribing to any particular cohort. You are the only one who ever sees your own Portrait data, and you can decide for yourself whether you think your prescribing is in line with the evidence given your unique clinical setting. You will only receive future Portraits for which you have prescribed more than the minimum inclusion criteria, so you shouldn’t receive anything that is irrelevant to your practice.
Why does my Portrait show ranges of patients that I treated (1-20, 20-30, etc.), and not exact numbers?
Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-5 patients), and percentages were rounded to the nearest 5%. Clinicians with no prescriptions (“0 prescriptions”) will have this element displayed.
I don’t see my question here. Where can I find more information?
Please check out our program FAQ section. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca.
No Comments