It’s no dream. Sleep well without sleeping pills.

David Gardner, BSc Pharm, MSc CH&E, PharmDProfessor, Department of Psychiatry

Sleep Medicine Update: What’s New in the World of Sleep Medicine

Judith Davidson, PhDAdjunct Professor, Department of Psychology

Objectives

1. Update the risks associated with seda6ve-hypno6cs.2. Introduce CBTi, the first-line treatment of insomnia you’ve

not heard of 3. Via Sleepwell, review tools to help Mari6mers use fewer

seda6ve-hypno6cs and more CBTi.

Conflicts of Interest

David Gardner Judith Davidson

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

Zopiclone use is not accounted for in these data. Zopiclone represents 25% of sedative-hypnotic use in Nova Scotia. These data substantially underestimate overall sedative use in Nova Scotia.

Wha

t abo

ut zo

picl

one?

Personal communication. Government of Nova Scotia. November 2018

02000400060008000

1000012000140001600018000

lorazepam

zopicl

one

clonazepam

diazepam

oxaxe

pam

alprazolam

temazepam

midazolam

bromazepam

clobazam

triazo

lam

chlordiaze

pozide

cloraze

pate

nitrazepam

Number of people dispensed a BZRA, Nova ScoHa, 2017 from all Pharmacare programs

How effec(ve are sleeping pills?

227

Placebo-20

Z-drug-42

Change intime to fall asleep (min.)

Huedo-Medina et al. BMJ 2012

14

Placebo+35

Z-drug+49

Increase in total sleep time (min.) Huedo-Medina et al. BMJ 2012

THE TRUE COST OF SEDATIVE-HYPNOTIC USE

How safe are sleeping pills?

Safety with other prescrip5on medica5ons, cough & cold remedies, alcohol, pain killers?

benzodiazepine + opioids overdose deaths

↑ 8x

How safe are sleeping pills?

Fractures

↑ 66% Berry et al. JAMA Intern Med. 2013 Donnelly et al. PLOS One 2017

Hip fractures:

↑ 52% to 90%

How safe are sleeping pills?

Injurious falls:

↑ 60%

Woolco9 et al. Arch Int Med 2009 Nakafero et al. Pharmacoepi Drug Saf 2016

Flu-related pneumonia

↑ 325%

How safe are sleeping pills?

Injurious falls:

↑ 60%

Woolcott et al. Arch Int Med 2009 Nakafero et al. Pharmacoepi Drug Saf 2016

Flu-related death

↑ 240% to 2000%

How safe are sleeping pills?

Worries, social withdrawal, isola6on,

loneliness

Risky driving, automobile accidents,

loss of independence

Zopiclone next day (10 am)

impairment:

≈ BAC .08

Verster et al. Residual effects of sleep medica6on on driving ability. Sleep Med Rev 2004; 8: 309-325.

ResultsResults show that zopiclone 7.5 mg has significant and clinically relevant performance-impairing effects on driving in the morning, 11 hours after bedtime ingestion. The effects did not differ between male and female subjects and did not increase with age. The effects of zopiclone 7.5 mg are comparable to the effects of a mean blood alcohol concentration between 0.5 and 0.8 mg/mL, …

Leufkens & Vermeeren. Mastricht University, Netherlands

How safe are sleeping pills?

Memory problems, cognitive impairment

Cogni9ve decline

How safe are sleeping pills?

The vicious cycle of medica8on use, dependence, and withdrawal

What is the leading cause of insomnia?

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

What is the name of the first-line recommended treatment for insomnia?

25

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.

26

Recommenda)on: CBT-I is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommenda6on, high-quality evidence).

A pharmacological interven7on can be offered if CBT-I is noteffec6ve 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

To achieve better insomnia treatment outcomes with CBTi.

To reduce sleeping pill use and related harms.

objectives

30

The 5 components of CBTi

31

32

33

34

CBTi workbooks

35

Each book:CBTi~$20Workbook styleEffec:ve when person is mo:vated, supported, dedicated

Apps, Websites, and Online Therapists

10:00 min

Stopping Sleeping Pills

Peggy is a 77 year old woman who has been treated with a BZRA for 10 years (and is also taking 9 other medica?ons regularly). What is the probability that she will successfully stop BZRA treatment within 6 months?

Peggy

0% 5% 25% 50% 90%

Empower brochure

EMPOWER Tannenbaum et al. JAMA Intern Med 2014

Pa7ents ~75 yo, 10 meds/dayBZRA ~10 yrsUse: insomnia 60%; anxiety 50%

Initial invitation Pharmacists: letter followed by phone callReferral to study team if interested. In-home meeting and consent.

Design Cluster RCT (30 pharmacies)

N 303

Intervention Booklet (by mail)

Outcomes 6 mo. d/c (>3 mo. no BZRA)6 mo. dose reduction or d/c

Interven'on Usual care

Stopped BZRA 27% 4.5%

Tannenbaum et al. JAMA Intern Med 2014

@6 months

Direct Patient Education: BZRA use reduction

https://mysleepwell.ca/sleeping-pills/terrys-story/

It’s no dream. Sleep well without sleeping pills.

David Gardner, BSc Pharm, MSc CH&E, PharmDProfessor, Department of Psychiatry

Sleep Medicine Update: What’s New in the World of Sleep Medicine

Judith Davidson, PhDAdjunct Professor, Department of Psychology