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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42 43

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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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