Study Finds Rising Long-Term Use of Hypnotics

Long-term use of benzodiazepine (BZD) and non-benzodiazepine hypnotics (NBH) in the United States appears to have grown significantly during a 15-year period between 1999 and 2014 independent of demographic shifts. The findings were published earlier this month in Psychiatric Services in Advance.

Because clinical guidelines suggest that both types of medications should be used on a short-term basis, the findings highlight “the pressing need for better delineation of appropriate medium- and long-term use of these medications,” wrote lead author Christopher Kaufmann, Ph.D., M.H.S., of the University of California, San Diego, and colleagues.

In an interview with Psychiatric News, Kaufmann said that most of the rise in non-benzodiazepine hypnotic prescriptions can be attributed to sleep problems, while about 30 percent of the prescriptions for benzodiazepines were for sleep. Most prescriptions for benzodiazepines were for anxiety, Kaufmann said.

The researchers analyzed data from eight waves of the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2014. NHANES interviewers recorded medications used during the preceding month based on prescription bottles provided by participants, and participants reported duration of use for each medication. BZDs included alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, oxazepam, temazepam, and triazolam. NBHs included zolpidem, zaleplon, and eszopiclone.

Kaufmann and colleagues found that use of both types of the medications increased significantly over the study period, from 2 percent of respondents in 1999-2000 to 4.2 percent in 2013-2014 for BZDs and from 0.4 percent in 1999-2000 to 1.6 percent in 2013-2014 for NBHs. The trends were driven by increases in use of more than six months.

The findings are concerning, Kaufmann said. “Long-term use of these medications is known to be associated with adverse outcomes, especially when used by older people who are at risk for falls and injuries.” There is also the risk that long-term use of the medications may lead to future abuse, he added.

Although the current report does not examine where individuals are receiving prescriptions for hypnotics, Kaufmann told Psychiatric News that previous research he has published showed that the rise in use of hypnotics is being driven by refills—not by first-time prescriptions—that are being ordered by primary care physicians.

A November 2016 report in the American Journal of Public Health by Kaufmann and colleagues looking at trends in hypnotic prescriptions between 2005 and 2012 found increases in continuing prescriptions for both benzodiazepines and non-benzodiazepines in primary care, but no change in prescriptions by psychiatrists. “The growth of continued non-benzodiazepine prescribing as a whole was attributable to prescribing increases in non-psychiatry specialties,” the authors wrote.

According to the Psychiatric Services study, in 2013-2014, 94 of the 96 listed NBHs (97.9 percent) were used for sleep problems, and of these, 85.1 percent were used on a medium- or long-term basis. Among the 290 BZDs listed, 60.3 percent were used for anxiety problems, 29.3 percent for sleep problems, and 11.4 percent for mood problems. About 83 percent of BZDs used for anxiety problems were for medium- or long-term use, as were most BZDs used for sleep problems (84.7 percent) and mood problems (81.8 percent).

“Monitoring of long-term BZD and NBH use, particularly in vulnerable patients (for example, older adults), may be important for understanding the reasons for changing patterns of use of these medications and prevention of potential adverse health outcomes associated with their use,” Kaufmann and colleagues wrote.

Petros Levounis, M.D., a consultant to the APA Council on Addiction Psychiatry who reviewed the report for Psychiatric News, said the findings provide research confirmation about what he said many clinicians know anecdotally. “We often say we prescribe benzodiazepines only for a short period of time, but the reality is different,” Levounis said. “It is good that this practice is exposed because benzodiazepines are associated with several negative outcomes, including falls, which is of great concern for our elderly patients. In general, benzodiazepines should be used only when absolutely necessary and only for short periods.”

Instead of prescribing hypnotics for sleep problems, Kaufmann recommended clinicians consider behavioral treatments, such as cognitive-behavioral therapy for insomnia.

Levounis noted that behavioral therapies for sleep disorders are underused. He said clinicians, especially in primary care, often do not have time to counsel patients about sleep, and insurance companies may not pay for these therapies. “So there ends up being a pressure on the clinician to do something for sleep problems,” he said.

The simplest thing to do for sleep problems often is to write a prescription for a hypnotic and to keep refilling the prescription, Levounis said.

Weaning patients off benzodiazepines can be a challenge, Levounis said. “Unless the patient has a compelling reason to taper quickly, such as pregnancy, the general concept is that the longer the taper the greater the chance of success,” he added.

This study was supported by a grant from the University of California, San Diego. ■