An international team of multidisciplinary researchers led by Canada's Dalhousie University in collaboration with Monash University have developed a simple and scalable direct-to-patient intervention to substantially reduce long-term sleeping pill use for the treatment of insomnia in older adults.
Sleeping pills for insomnia include a class of medications called benzodiazepines. In Australia, approximately 7 million benzodiazepine prescriptions are recorded through the Pharmaceutical Benefits Scheme each year, with long‐term prescribing up to six times more likely in elderly patients, despite the serious associated risks such as cognitive impairment, injurious falls, motor vehicle collisions, pneumonia and frailty.
In this Canada-based randomised controlled trial, published in JAMA Psychiatry, the team of researchers randomly allocated a total of 1295 individuals into three groups, with sleeping pill use at six months into the trial being the primary measure.
The two intervention groups were named 'Sleepwell' and 'Eliminating Medications Through Patient Ownership of End Results' (EMPOWER). With the third group (the control group), there was no intervention.
Of the two intervention groups, Sleepwell had the highest overall rate (46.6 per cent) of sleeping pill discontinuation and dose reduction at the six month mark, compared with EMPOWER which led to a 34.8 per cent overall reduction.
Co-author, Dr Justin Turner from the Centre for Medicine Use and Safety within the Monash Institute of Pharmaceutical Sciences, said the emphasis on cognitive behavioural therapy for insomnia (CBTI) appears to have given Sleepwell an edge over alternative approaches.
"With Sleepwell, individuals were given two booklets – How to Stop Sleeping Pills and How to Get Your Sleep Back – along with access to a website. The content and graphics were specifically designed to integrate behaviour change techniques to decrease sleeping pill use and increase cognitive behavioural therapy for insomnia," Dr Turner said.
"While the EMPOWER approach also saw a noteworthy reduction in sleeping pill use, the absence of cognitive behavioural therapy for insomnia meant it did not yield the same success rate as Sleepwell."
Cognitive behavioural therapy for insomnia is evidence-based and the first line treatment for insomnia. It is not an immediate quick fix; however, it has proven to be highly effective and beneficial for individuals with insomnia and, unlike sleeping pills, the effect is long-lasting.
Lead author, Professor David Gardner, whose work focuses on improving the safe and effective use of psychiatric medications at Canada's Dalhousie University said most efforts and campaigns to reduce the high rate of sleeping pill use among older adults have focused on educating health care professionals. "For this study, we went straight to the people taking the sleeping pills," Professor Gardner said. "Encouragingly, in addition to reducing their use of sleeping pills, people in the Sleepwell group had better sleep and less daytime sleepiness compared to the other groups." The prevalence of insomnia increases with age as does the use of sleeping pills and the burden of their adverse effects. Avoiding sleeping pill use is widely endorsed and associated with a decrease in harm and mortality, health cost savings and improved quality of life. According to the Australian Government's Institute of Health and Welfare, more than two in five (46 per cent) of drug-related hospitalisations in 2021-22 were attributed to benzodiazepines. While the number of benzodiazepine-related hospitalisations has been on the decline in Australia, the problem remains significant and is still resulting in far too many adverse health outcomes and unnecessary deaths, particularly among older adults. "The need for more evidence-based interventions is still a pressing one," Dr Turner said. "Although the Sleepwell/EMPOWER trial was conducted in Canada, the comparison between Australia and Canada is natural because of their similar demographic profiles and healthcare systems. Taking this into account, we would encourage the Australian government to consider implementing and evaluating this direct-to-patient educational approach and empower Australians to make informed decisions about their sleeping pill use."
