What is the Cost of a Good Night’s Sleep?

This Top Paper¹ is a cautionary tale of a disconcerting primary care complicity, the power of direct-to-consumer marketing, and insomnia, played out in the context of a common practice—that of prescription hypnotic drugs.

The Stats

A population-based cohort study¹ identified 8188 patients who were first given a zolpidem prescription between January 2000 and December 2009. The zolpidem cohort was then compared to 32,752 age- and sex-matched controls that had not used hypnotic agents. Both groups were followed for at least 1 year, or until hospitalization for a head injury or fracture. 

The results were disturbing. The adjusted hazard ratio for a major head injury in zolpidem users versus the control group was 1.67. Lest one get the sense that zolpidem may be a problem only in an older age group, younger subjects (ages 18-54) taking zolpidem reported a hazard ratio of 1.70 compared to older participants (age >55) who had a hazard ratio of 1.57. 

And, not surprisingly, inflating zolpidem usage also substantially increased the risk for injury; the hazard ratio was 4.74 when zolpidem dosage exceeded 1600 mg/year.    

Prescription Hypnotics 

I found this information disturbing on multiple levels. Unfortunately, it is a template that is repeated with several pharmaceuticals. The accompanying editorial² described “alluring images” expressed in advertising for hypnotics: a glowing moth, roosters banished from the bedroom, and a moon tethered in a placid sky culminating in a woman sleeping peacefully. The Top Paper¹ seems to suggest that the images portrayed in advertising do not tell the whole story. The advertising template is reprised with testosterone replacement therapies. 

Yet, when one compares the popularity and volume of prescriptions for testosterone in the United States (with direct-to-consumer marketing) to Canada and Great Britain (without direct-to-consumer marketing), the power of television imagery becomes apparent.

Insomnia diagnoses increased 7-fold from 1993 to 2007.² If you think that increase is impressive, hold on. Prescriptions for hypnotics increased 30 times in the same interval.²

Note: The editorial² did not solely criticize prescription hypnotics without offering an alternative. Cognitive behavioral therapy (CBT) is at least as effective as hypnotics.² However, physicians do not receive training in CBT or in pain management.² More insight into the risks accompanying hypnotics, testosterone, and opiates is essential. 

The accompanying editorial² said it best, “In the United States and worldwide, we have serious problems with sleep that are robbing us of our vitality, health and wealth, and more than a pill is required to address them.”² The same can be said for the recent testosterone replacement craze. I, for one, do not want to be medicalizing every aspect of insomnia and fatigue in response to television marketing. ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

References:

1.Lai MM, Lin CC, Lin CC, et al. Long-term use of zolpidem increases the risk of major injury: a population-based cohort study. Mayo Clin Proc. 2014;89(5):589-594.

2.Morgenthaler TI. The sirens of sleep. Mayo Clin Proc. 2014;89(5):579-582. hives.