Despite Alternatives, Addictive Drugs Most Often Prescribed For Sleep Problems

Office visits by older patients and those with publicly funded health insurance plans were nearly twice as likely to result in the prescription of these kinds of medications.

The drugs, called benzodiazepines, are often a cheaper alternative to some newer types of medicines that don't have the same potentially addictive side effects, said Rajesh Balkrishnan, the study's lead author and the Merrell Dow professor of pharmacy at Ohio State University .

“Some of the most vulnerable populations in the United States are at greater risk of receiving prescription sleep medication with a high abuse potential,” he said.

The study, which appears in the current issue of the journal Sleep, includes data from 94.6 million office visits in the United States over a six-year period. Patients included in the data set sought help for sleep-related difficulties in outpatient physician offices.

Balkrishnan and his colleagues gathered six years of outpatient office visit data – from 1996 to 2001 – from the National Ambulatory Medical Care Survey (NAMCS). The NAMCS includes information on patient demographics, the reason for a visit, a patient's diagnosis, the medication prescribed and the therapeutic and preventive services recommended during that visit. The majority of patients went to family practice physicians, internal medicine providers or psychiatrists.

Using information from the NAMCS, the researchers analyzed the treatment patterns of patients 18 and older who reported sleep problems.

Nearly two-thirds of those visits resulted in medication prescriptions for a person's sleep difficulties, and three-quarters of those prescriptions were for a benzodiazepine. (Five of the 13 kinds of benzodiazepines on the market in the United States are indicated for treating insomnia.)

The other 25 percent of patient visits for sleep disorders ended with prescriptions for non-benzodiazepine medications.

Benzodiazepines were widely prescribed for anxiety and other stress-related problems in the 1960s and 1970s. These drugs, which have a calming effect on the nervous system, are still prescribed as muscle relaxants and tranquilizers. (Valium is one example of a benzodiazepine, although it is not recommended for treating insomnia in the United States.)

“Benzodiazepines are usually effective for just a few weeks when used to treat insomnia. But addiction can develop relatively quickly”, Balkrishnan said.

“A person can develop a strong psychological and physical dependence on these drugs in a short time, and experience severe withdrawal-like symptoms once he stops taking the medication,” he said.

Office visits by people 50 and older were about 5 times as likely to result in a drug treatment for sleep problems as were visits by 18- to 34-year-olds.

And people 65 and older were twice as likely as the 18- to 34-year-olds to receive prescriptions for benzodiazepines. Visits by patients with Medicare or Medicaid – the federally subsidized health insurance plans – were also twice as likely to result in benzodiazepine prescriptions as visits by patients with private health insurance.

Psychiatrists were four times as likely to prescribe newer non-benzodiazepine drugs during patient visits compared to family practice and internal medicine physicians.

“Psychiatrists may be more informed than other kinds of doctors about newer, non-benzodiazepine drugs,” Balkrishnan said. “Or psychiatrists may see patients with more complex problems in whom other therapies such as over-the-counter medications have failed.

“Overall, the study suggests that some physicians do consider other options before jumping to prescribe a drug to treat sleep problems,” he said.

But many health care providers don't take public health insurance, Balkrishnan said. This means that these patients, regardless of their age, are more likely to receive cheaper benzodiazepines as treatments for their sleep problems.

And elderly people, 65 and older, with private health insurance were more likely to receive benzodiazepines.

“We need to understand the reasons for these disparities in order to stop this trend,” Balkrishnan said. “There needs to be a move toward a more uniform prescription system – at least for certain types of medications.

“One possibility is to create guidelines that say let's reserve the most addictive benzodiazepines for patients for whom every other kind of treatment has been unsuccessful.”

While the study did not look at the types of non-drug treatments prescribed to treat sleep disorders, such as behavioral therapy, the researchers found that nearly half (48 percent) of patient visits resulted in a drug prescription, while 14 percent of the office visits resulted in a combined prescription of medication and behavioral therapy. Just five percent of patient visits resulted in prescribed behavioral therapy only.

The study was funded by a grant from Takeda Pharmaceuticals of North America, Inc., Lincolnshire, Ill. The study does not discuss any specific products of the sponsor company.