It’s no dream. Sleep well without sleeping pills.
David Gardner, BSc Pharm, MSc CH&E, PharmDProfessor, Department of Psychiatry & College of Pharmacy
my .ca
As we get older …
• We often need to take more medications to manage chronic conditions
• The benefits and risks of medications may change
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As we get older
• The brain becomes more sensitive to drug effects
• Medications stay longer in our body – less muscle
– more body fat
– liver and kidneys not as efficient as when we were younger
• Higher concentrations of medications – body contains less water & muscle
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Report
© 2018
Medication use in Canadians 65+ Medication use in Canadians 65+
Medication side effects can be serious, resulting in hospitalizations
If 65+ taking the following number of medication classes:
Probability of being hospitalized due to adverse effects in 2016 was:
1 - 4 1 in 500
5-9 1 in 175
10-14 1 in 70
15+ 1 in 35
1. DEPRESCRIBING2. POTENTIALLY INAPPROPRIATE MEDICATIONS (PIMS)
Today’s new terms:
DeprescribeReducing and stopping medications to improve health and reduce adverse effect burden and risk.
Potentially Inappropriate MedicationsIdentified as a medication with high risk for harm, especially in older adults, … when safer management alternatives exist.
PIM examples
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• Chronic use of anti-inflammatory medications such as ibuprofen or naproxen (non-steroidal anti-inflammatory drugs or NSAIDs)
• Antipsychotic medication when used as a sleeping pill or for dementia (e.g. quetiapine/Seroquel®, risperidone/Risperdal®)
• Long-acting sulfonylureas (type-2 diabetes medications) (e.g. glyburide/Diabeta®)
• Sleeping pills (e.g. alprazolam/Xanax®, zolpidem/Sublinox®)
• Stomach pills for more than 8 weeks in acid reflux disease : proton-pump inhibitors (e.g. pantoprazole/Pantoloc®)
Potentially Inappropriate Medications (PIMs)
Canadians 65+ who take at least one PIM
Morgan et al. 2016. CMAJ Open; 4: E346-E51.
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Are you taking any of these medications for insomnia?ZopicloneImovane
LorazepamAtivan
TriazolamHalcion
ClorazepateTranxene
ZolpidemSublinox, Ambien
DiazepamValium
AlprazolamXanax
EstazolamProsom
EszopicloneLunesta
OxazepamSerax
ClonazeapmRivotril
Chlordiaze-poxideLibrium
Zaleplon Sonata
TemazepamRestoril
FlurazepamDalmane
BromazepamLectopam
What about any of these ones?
Chloral hydrate
TrazodoneDesyrel
AmitriptylineElavil
DoxepinSinequan
QuetiapineSeroquel
DiphenhydramineBenadryl
DimenhydrinateGravol
Melatonin L-tryptophan Valerian root
Rate of benzodiazepine use by province
0 10000 20000 30000 40000 50000
SK
BC
ON
AB
National
QC
MB
PE
NS
NL
NB
Benzodiazepines’unit dispensing rates in 2013 per 100 seniors
Black et al. Can Geriatrics J 2018
1.44 2.76
Zopiclone not included. Lower rates of zopiclone in provinces that do not cover zopiclone: SK, QC.
0 10000 20000 30000 40000 50000 60000
SK
BC
ON
AB
National
QC
MB
PE
NL
NS
NB
Benzodiazepines (left) and trazodone (right)unit dispensing rates in 2013 per 100 seniors
Rate of sedative use by province
Black et al. Can Geriatrics J 2018
1.4 2.6
Zopiclone not included. Lower rates of zopiclone in provinces that do not pay for zopiclone: SK, QC.
What about adults?
62 66 67 66 65 68
1216
22 29 3438
1 9 9 6 1 9 9 9 2 0 0 2 2 0 0 5 2 0 0 8 2 0 1 1
PREV
ALEN
CE/1
000
POPU
LATI
ON
MANITOBA - ADULTS (18-64)PREVALENCE/1000 POPULATION
Benzodiazepines Z-drugs
* Prevalence: # of users within 4 month period Alessi-Severini et al. CMAJ Open 2014
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New York Times
Drug-drug interaction fact
When opioids are used with sleeping pills, the risk of death increases.
U.S. data:
What fraction of deaths involving opioids in people 65+ also included sleeping pills?
Humphries. NEJM Feb 22, 2018
~2/3rds
How effective are sleeping pills?
227
Placebo-20
Z-drug-42
Change intime to fall asleep (min.)
Huevo-Medina et al. BMJ 2012
14
Placebo+35
Z-drug+49
Increase in total sleep time (min.) Huevo-Medina et al. BMJ 2012
THE TRUE COST OF SEDATIVE-HYPNOTIC USE
How safe are sleeping pills?
Safety with other prescription medications, cough & cold remedies, alcohol, pain killers?
Risk for falls, injuries, pneumonia, …
How safe are sleeping pills? Number of injury related hospital admissions and proportion related to falls in Nova Scotia, 2000-2004
745025%
710020%
640017%
590015%
655038%
450052%
250067%
# IRH% falls
The cost of falls 1/3rd of fall-related hospitalizations in people 65+ involve hip fracturesSource: CIHI 2014Preventing Falls: From Evidence to Improvement in Canadian Health Care.
Population Attributive Risk of Benzodiazapines for Injurious Falls resulting in hospitalization
Panneman MJ et al. Drugs Aging. 2003
Injurious falls in 70-80 year olds: BZDs account for ~5% (men) to ~10% (women)
Injurious falls in 85+ yo: BZDs account for >30% (men) and >40% (women)
How safe are sleeping pills?
Worries, social withdrawal, isolation, loneliness
Risky driving, automobile accidents, loss of independence
How safe are sleeping pills?
Memory problems, cognitive impairment
Cognitive decline
How safe are sleeping pills?
The vicious cycle of medication use, dependence, and withdrawal
Withdrawal symptoms:• insomnia• anxiety• irritability• headaches• sweating• shaking or tremors• pounding heart• nausea• dizziness• unsteadiness• difficulty concentrating• sensitivity to noise and
light• ringing in the ears• confusion/delirium• depression• seizures
to stop sleeping pills AND get a good night’s sleep
To achieve better insomnia treatment outcomes with CBTi.
To reduce sleeping pill use and related harms.
objectives
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Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder.
There are various delivery methods for CBT-I, such as individual or group therapy, telephone or Web-based modules, or self-help books.
Qaseem et al. Ann Intern Med. 2016 (Jul 16);165:125-133.
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Recommendation: CBT-I is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence).
A pharmacological intervention can be offered if CBT-I is noteffective or not available.
Riemann et al. J Sleep Res. 2017;26:675-700.
European Sleep Research Society 2017
older adults
adults
adolescents
depression
anxiety
pain
fibromyalgia
menopause
cancer
stop hypnotics
THERAPIST
BOOK
ONLINE
APP
Insomnia and CBTi workbooks
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Each book:CBTi~$20Workbook styleEffective when patient is motivated, supported, dedicated
mysleepwell.ca
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The 5 components of CBTi
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Proportion of seniors who are chronic users of benzodiazepines
Source: Canadian Institute for Health Information*Self report (Qc.)
20.9% ↑1.3%
16.4% ↓0.5%
25.1% ↑0.9%
5.3% ↓1.1% 8.7%
↓1.9%
Chronic users: one or more claims for a benzodiazepine or other related drug (i.e., z-drug) in a given year, totalling at least 90 continuous supply days, without a gap in supply of at least 30 days
2014-2015 (& 4-year trend)
8.6% ↓1.2% 15.8%
↓0.5% 15.7% ↓1.0%
58% above Canadian avg.
Canada10.4% ↓1.5%
Booklet 1How To Get Your Sleep Back
Booklet 2How to Stop Sleeping Pills
Empower brochure
Research Program
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