EDITORIAL May 2014 Volume 89 Number 5
The Sirens of Sleep?
I
n this issue of Mayo Clinic Proceedings, Lai et al,1 representing multiple academic institutions in Taichung, Taiwan, report on a population-based cohort study that evaluated the risks of major injury associated with use of the hypnotic drug zolpidem. It is a strong study with a large data set and a straightforward design. The investigators discovered that occasional, frequent, and long-term zolpidem use was associated with notable increased risks of head injuries or fractures associated with hospitalization. Their data reveal that the risk of serious injury among those using zolpidem is approximately 60% greater than that of controls for young and older patients alike, and the hazard ratio increases in a dosedependent fashion. We should be concerned about these high risks. These findings add to the already concerning literature about risks of zolpidem for personal injury, which has thus far predominantly focused on the risks of falls in the elderly population or falls in acutely ill hospitalized patients.2 The report by Lai et al1 provides an opportunity to review the broad health care implications of sleep disorders; the prevalence of, and rationale for, hypnotic drug prescription; and hypnotic drugs’ risk-benefit profile when used to promote bedtime sleep. Hypnotic drugs are an enticing balm for symptoms of insomnia. Alluring images within advertisements promoting these drugsdsuch as the glowing Luna moth, the sleeping blonde women in quiet repose, pesky roosters banished from the bedroom, the moon tethered in a placid sky, and a darkened bedroomdare designed to suggest that blissful sleep will surely follow the ingestion of prescription hypnotics. But when we prescribe a hypnotic, are we luring our patients to sleep or are we luring them to the rocks of destruction like the sirens of old? Practicing physicians of all specialties, public health policy makers, and
patients need to be aware of several key facts about the use hypnotic drugs to treat insomnia. Sleep disorders including insomnia are common, serious, and costly. An estimated 50 to 70 million adults in the United States have chronic sleep and wakefulness disorders.3 Insomnia affects approximately 10% to 15% of American adults, costs $75 to $100 million in health care expenses and $100 billion in lost productivity, and is associated with a profoundly negative effect on health-related quality of life.4,5 Insomnia is a frequent comorbid condition that seriously adversely affects the underlying prognosis of many medical conditions. For example, in patients with chronic obstructive pulmonary disease, concurrent insomnia is common and is independently associated with a 4-fold increased rate of exacerbations, an 11-fold increase in respiratory-related emergencies, worse cardiovascular outcomes, and a 5-fold higher mortality.6,7 Although most patients who have sleep difficulties never consult a physician,8 increasing numbers of patients are seeking assistance. From 1993 to 2007, the number of adult office visits with concerns about sleeplessness as one of the top 3 reasons for the visit increased nearly 100% to 5.7 million.4 Insomnia diagnoses increased by 700% to approximately 6.1 million over that same interval. Thus, many patients are seeking help from physicians and other health care professionals who often have only scant training in the management of sleep disordersdthe average medical school curriculum devotes less than 3 hours to sleep diseases.9 Cognitive behavioral therapy (CBT) for insomnia includes psychological techniques aimed at modifying misconceptions about sleep, insomnia, and perceived daytime consequences, as well as behavioral methods such as stimulus control, sleep restriction therapy, relaxation training, and educational methods.
Mayo Clin Proc. n May 2014;89(5):579-582 n http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
See also page 589
579
MAYO CLINIC PROCEEDINGS
Despite many studies reporting that CBT is at least as effective as hypnotics, physicians increasingly prescribe hypnotics to address insomnia concerns.10 The tendency to prescribe hypnotics instead of deploying CBT is no doubt due to the fact that most physiciansdother than sleep specialists or psychiatristsdreceive little or no training in CBT, have limited time to provide CBT, and often have little access to other professionals trained in CBT. The specialty of behavioral sleep medicine has only recently been established, and there is clearly an urgent need for expansion of CBT capabilities. No doubt the perceived inadequate CBT options drive concerned physicians, advanced practice nurses, and physician assistants to prefer prescribing a hypnotic when confronted with a sleep-distressed patient. The medicalization of insomnia by the powerful pharmaceutical industry may cause patients to expect pharmacological therapy.11 Although the frequency of insomnia diagnoses increased by a factor of 7-fold from 1993 to 2007, prescriptions for hypnotics increased more dramatically, with a 30-fold increase in prescriptions for nonbenzodiazepine sedative hypnotics.11 This increase in hypnotic drug use may be due in part to an actual increase in insomnia prevalence but could also be fueled by increased direct-to-consumer advertisement and the projection of relative drug safety to prescribers. For example, in the United States, sales of zolpidem and eszopiclone in 2006 exceeded $3 billion, and in the same year, makers of sleeping pills spent more than $600 million on advertising aimed at consumers.12 Perhaps not coincidentally, the nonbenzodiazepine receptor agonists (nonBDZRAs) eszopiclone, zaleplon, and zolpidem are largely responsible for the growth in hypnotic use and were prescribed more than twice as commonly as any other hypnotics for insomnia symptoms. Approximately 1.23% of the US population is using a nonBDZ-RA at least once each month.4 Nonbenzodiazepine receptor agonist hypnotics are helpful in treating insomnia, and I am glad they are available. In contrast to less selective benzodiazepines or alcohols, nonBDZ-RAs work by selectively binding to the a-1 subtype g-aminobutyric acid type A subunit (thereby preferentially causing sedation) and are less likely to cause muscle 580
Mayo Clin Proc.
n
relaxation or anxiolysis. Because of the selectivity of their pharmacological targets, nonBDZ-RAs have generally been portrayed with a more favorable adverse effect profile than the nonselective benzodiazepines. For example, they are considerably less frequent drugs of abuse or dependency than the benzodiazepines that previously dominated the hypnotic armamentarium.13 However, here is the fourth fact that must be acknowledged: there is increasing evidence that nonBDZ-RAs are associated with considerable risks of complex sleep-related behaviors, falls, and other injuriesdrisks substantial enough that we need to take note. Zolpidem, by far the most commonly prescribed nonBDZ-RA, has previously been reported to be associated with many serious risks, including gait unsteadiness,14 increased traffic accidents after use,15,16 increased falls in community-based and skilled nursing facilityehomed elderly residents,2 increased falls in hospitalized patients,17 amnestic sleeprelated eating,18,19 sleep driving,19 amnestic sleep-related sex acts, and other complex sleeprelated behaviors.20 The association with unusual behaviors has garnered much press, perhaps because some of the behaviors seem so colorful. However, there may be even more serious risks. To review, insomnia concerns are common. Cognitive behavioral therapy is a safe and effective therapy, but because it is often unavailable, hypnotic use is increasing. An increasing number of Americans and others worldwide use hypnotic drugs, and experience with this class of drugs is making it increasingly apparent that they are not as safe as originally perceived. These hypnotic drugs increase the risk of serious injury by up to 60% and the risk of an inpatient falling by a factor of 4 to 6, and they double the risks of motor vehicular accidents (especially among women).21 In view of these problems, what should physicians, public health policy makers, and patients do? Physicians and patients must be aware that zolpidem (and other hypnotics) carry major risks of harm, particularly if not used correctly. In many cases, insomnia may be prevented or improved by attention to lifestyle and sleep habits.10 Obtaining an accurate diagnosis of the causes of insomnia, expanded use of sleep hygiene coaching (providing general guidelines about diet and exercise; avoidance of caffeine,
May 2014;89(5):579-582
n
http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org
EDITORIAL
nicotine, and alcohol; attention to environmental factors that may promote or interfere with sleep; and adherence to salutary sleep schedules), and CBT should at least be considered before hypnotics. In medical settings that do not have access to in-person CBT, patients should still consider the use of proven online CBT methods,22-24 and forward-thinking health care systems should find ways to provide CBT because it is cost-effective and safe.25 Before considering a hypnotic drug, a careful riskbenefit assessment should be performed for each patient. Is the patient already at increased risk for falling or serious injury when falling? Is the patient capable of adhering to the bestpractice recommendations for use? When zolpidem (or another hypnotic) is prescribed, the minimal effective dose should be used for the minimal required time, patients should not use alcohol or other sedatives concurrently, they should take the medication only immediately before going to bed to sleep, and they should allow the specified time to sleep before awakening. Public health policy makers must take steps to help increase the availability of information to patients about the importance of sleep health, healthy sleep habits, and the effectiveness of CBT. Such measures might include increased education and training about CBT for physicians, advanced practice nurses, and physician assistants and incentives that increase patient access to other professionals who can provide CBT. The new National Healthy Sleep Awareness Project aims to improve sleep health policies, educate patients about behavior changes that can lead to improved sleep health and quality of life, and improve the quality, delivery, and use of clinical and other services to address the management and prevention of sleep disorders.26 This joint project of the American Academy of Sleep Medicine, the Sleep Research Society, and the Centers for Disease Control and Prevention is just an example of the type of collaborative effort required to tackle this public health issue, and programs like these need augmented and ongoing funding. 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. We need to be wary of the sirens of sleep. Mayo Clin Proc. n May 2014;89(5):579-582 www.mayoclinicproceedings.org
n
Timothy I. Morgenthaler, MD Mayo Clinic Center for Sleep Medicine Division of Pulmonary and Critical Care Medicine Mayo Clinic Rochester, MN Correspondence: Address to Timothy I. Morgenthaler, MD, Mayo Clinic Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]).
REFERENCES 1. Lai M-M, Lin C-C, Lin C-C, Liu C-S, Li T-C, Kao C-H. Longterm use of zolpidem increases the risk of major injury: a population-based cohort study. Mayo Clin Proc. 2014;89(5): 589-594. 2. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Zolpidem use and hip fractures in older people. J Am Geriatr Soc. 2001;49(12): 1685-1690. 3. Institute of Medicine (US) Committee on Sleep Medicine and Research. In: Colten HR, Altevogt BM, eds. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academies Press; 2006. 4. Bertisch SM, Herzig SJ, Winkelman JW, Buettner C. National use of prescription medications for insomnia: NHANES 1999-2010. Sleep. 2014;37(2):343-349. 5. Buscemi N, Vandermeer B, Friesen C, et al; University of Alberta Evidence-based Practice Center, United States; Agency for Healthcare Research and Quality. Manifestations and Management of Chronic Insomnia in Adults. Rockville, MD: Agency for Healthcare Research and Quality; 2005:Evidence Report/Technology Assessment 125. AHRQ Publication 05E021-2. 6. Budhiraja R. Insomnia in chronic obstructive pulmonary disease: breathless and sleepless [editorial]. Sleep Med. 2013;14(12): 1233-1234. 7. Omachi TA, Blanc PD, Claman DM, et al. Disturbed sleep among COPD patients is longitudinally associated with mortality and adverse COPD outcomes. Sleep Med. 2012;13(5): 476-483. 8. Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I. Sleep. 1999;22(suppl 2):S347-S353. 9. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep. 1998;21(3):235-238. 10. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update; an American Academy of Sleep Medicine report. Sleep. 2006;29(11):1415-1419. 11. Moloney ME, Konrad TR, Zimmer CR. The medicalization of sleeplessness: a public health concern. Am J Public Health. 2011;101(8):1429-1433. 12. Saul S. F.D.A. warns of sleeping pills’ strange effects. New York Times website. http://www.nytimes.com/2007/03/15/business/ 15drug.ready.html?pagewanted¼all&_r¼0#. Published March 17, 2007. Accessed February 18, 2014. 13. Hajak G, Müller WE, Wittchen HU, Pittrow D, Kirch W. Abuse and dependence potential for the nonbenzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addiction. 2003; 98(10):1371-1378. 14. Avidan AY, Fries BE, James ML, Szafara KL, Wright GT, Chervin RD. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc. 2005;53(6):955-962. 15. Yang YH, Lai JN, Lee CH, Wang JD, Chen PC. Increased risk of hospitalization related to motor vehicle accidents among
http://dx.doi.org/10.1016/j.mayocp.2014.03.006
581
MAYO CLINIC PROCEEDINGS
16.
17.
18. 19.
20.
21. 22.
582
people taking zolpidem: a case-crossover study. J Epidemiol. 2011;21(1):37-43. Farkas RH, Unger EF, Temple R. Zolpidem and driving impairmentdidentifying persons at risk. N Engl J Med. 2013;369(8): 689-691. Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6. Morgenthaler TI, Silber MH. Amnestic sleep-related eating disorder associated with zolpidem. Sleep Med. 2002;3(4):323-327. Poceta JS. Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series. J Clin Sleep Med. 2011;7(6):632-638. Dolder CR, Nelson MH. Hypnosedative-induced complex behaviours : incidence, mechanisms and management. CNS Drugs. 2008;22(12):1021-1036. Gunja N. In the Zzz zone: the effects of Z-drugs on human performance and driving. J Med Toxicol. 2013;9(2):163-171. Espie CA, Fleming L, Cassidy J, et al. Randomized controlled clinical effectiveness trial of cognitive behavior therapy
Mayo Clin Proc.
n
23.
24.
25.
26.
compared with treatment as usual for persistent insomnia in patients with cancer [published correction appears in J Clin Oncol. 2010;28(19):3205]. J Clin Oncol. 2008;26(28): 4651-4658. Holmqvist M, Vincent N, Walsh K. Web- vs. telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Med. 2014;15(2):187-195. Thorndike FP, Ritterband LM, Gonder-Frederick LA, Lord HR, Ingersoll KS, Morin CM. A randomized controlled trial of an Internet intervention for adults with insomnia: effects on comorbid psychological and fatigue symptoms. J Clin Psychol. 2013;69(10):1078-1093. McCrae CS, Bramoweth AD, Williams J, Roth A, Mosti C. Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs. J Clin Sleep Med. 2014; 10(2):127-135. Heffron T. Promoting healthy sleep with the CDC. American Academy of Sleep Medicine website. http://www.sleepeducation. com/news/2013/11/14/promoting-healthy-sleep-with-the-cdc. Published November 14, 2013. Accessed February 23, 2014.
May 2014;89(5):579-582
n
http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org
The Sirens of Sleep?
I
n this issue of Mayo Clinic Proceedings, Lai et al,1 representing multiple academic institutions in Taichung, Taiwan, report on a population-based cohort study that evaluated the risks of major injury associated with use of the hypnotic drug zolpidem. It is a strong study with a large data set and a straightforward design. The investigators discovered that occasional, frequent, and long-term zolpidem use was associated with notable increased risks of head injuries or fractures associated with hospitalization. Their data reveal that the risk of serious injury among those using zolpidem is approximately 60% greater than that of controls for young and older patients alike, and the hazard ratio increases in a dosedependent fashion. We should be concerned about these high risks. These findings add to the already concerning literature about risks of zolpidem for personal injury, which has thus far predominantly focused on the risks of falls in the elderly population or falls in acutely ill hospitalized patients.2 The report by Lai et al1 provides an opportunity to review the broad health care implications of sleep disorders; the prevalence of, and rationale for, hypnotic drug prescription; and hypnotic drugs’ risk-benefit profile when used to promote bedtime sleep. Hypnotic drugs are an enticing balm for symptoms of insomnia. Alluring images within advertisements promoting these drugsdsuch as the glowing Luna moth, the sleeping blonde women in quiet repose, pesky roosters banished from the bedroom, the moon tethered in a placid sky, and a darkened bedroomdare designed to suggest that blissful sleep will surely follow the ingestion of prescription hypnotics. But when we prescribe a hypnotic, are we luring our patients to sleep or are we luring them to the rocks of destruction like the sirens of old? Practicing physicians of all specialties, public health policy makers, and
patients need to be aware of several key facts about the use hypnotic drugs to treat insomnia. Sleep disorders including insomnia are common, serious, and costly. An estimated 50 to 70 million adults in the United States have chronic sleep and wakefulness disorders.3 Insomnia affects approximately 10% to 15% of American adults, costs $75 to $100 million in health care expenses and $100 billion in lost productivity, and is associated with a profoundly negative effect on health-related quality of life.4,5 Insomnia is a frequent comorbid condition that seriously adversely affects the underlying prognosis of many medical conditions. For example, in patients with chronic obstructive pulmonary disease, concurrent insomnia is common and is independently associated with a 4-fold increased rate of exacerbations, an 11-fold increase in respiratory-related emergencies, worse cardiovascular outcomes, and a 5-fold higher mortality.6,7 Although most patients who have sleep difficulties never consult a physician,8 increasing numbers of patients are seeking assistance. From 1993 to 2007, the number of adult office visits with concerns about sleeplessness as one of the top 3 reasons for the visit increased nearly 100% to 5.7 million.4 Insomnia diagnoses increased by 700% to approximately 6.1 million over that same interval. Thus, many patients are seeking help from physicians and other health care professionals who often have only scant training in the management of sleep disordersdthe average medical school curriculum devotes less than 3 hours to sleep diseases.9 Cognitive behavioral therapy (CBT) for insomnia includes psychological techniques aimed at modifying misconceptions about sleep, insomnia, and perceived daytime consequences, as well as behavioral methods such as stimulus control, sleep restriction therapy, relaxation training, and educational methods.
Mayo Clin Proc. n May 2014;89(5):579-582 n http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
See also page 589
579
MAYO CLINIC PROCEEDINGS
Despite many studies reporting that CBT is at least as effective as hypnotics, physicians increasingly prescribe hypnotics to address insomnia concerns.10 The tendency to prescribe hypnotics instead of deploying CBT is no doubt due to the fact that most physiciansdother than sleep specialists or psychiatristsdreceive little or no training in CBT, have limited time to provide CBT, and often have little access to other professionals trained in CBT. The specialty of behavioral sleep medicine has only recently been established, and there is clearly an urgent need for expansion of CBT capabilities. No doubt the perceived inadequate CBT options drive concerned physicians, advanced practice nurses, and physician assistants to prefer prescribing a hypnotic when confronted with a sleep-distressed patient. The medicalization of insomnia by the powerful pharmaceutical industry may cause patients to expect pharmacological therapy.11 Although the frequency of insomnia diagnoses increased by a factor of 7-fold from 1993 to 2007, prescriptions for hypnotics increased more dramatically, with a 30-fold increase in prescriptions for nonbenzodiazepine sedative hypnotics.11 This increase in hypnotic drug use may be due in part to an actual increase in insomnia prevalence but could also be fueled by increased direct-to-consumer advertisement and the projection of relative drug safety to prescribers. For example, in the United States, sales of zolpidem and eszopiclone in 2006 exceeded $3 billion, and in the same year, makers of sleeping pills spent more than $600 million on advertising aimed at consumers.12 Perhaps not coincidentally, the nonbenzodiazepine receptor agonists (nonBDZRAs) eszopiclone, zaleplon, and zolpidem are largely responsible for the growth in hypnotic use and were prescribed more than twice as commonly as any other hypnotics for insomnia symptoms. Approximately 1.23% of the US population is using a nonBDZ-RA at least once each month.4 Nonbenzodiazepine receptor agonist hypnotics are helpful in treating insomnia, and I am glad they are available. In contrast to less selective benzodiazepines or alcohols, nonBDZ-RAs work by selectively binding to the a-1 subtype g-aminobutyric acid type A subunit (thereby preferentially causing sedation) and are less likely to cause muscle 580
Mayo Clin Proc.
n
relaxation or anxiolysis. Because of the selectivity of their pharmacological targets, nonBDZ-RAs have generally been portrayed with a more favorable adverse effect profile than the nonselective benzodiazepines. For example, they are considerably less frequent drugs of abuse or dependency than the benzodiazepines that previously dominated the hypnotic armamentarium.13 However, here is the fourth fact that must be acknowledged: there is increasing evidence that nonBDZ-RAs are associated with considerable risks of complex sleep-related behaviors, falls, and other injuriesdrisks substantial enough that we need to take note. Zolpidem, by far the most commonly prescribed nonBDZ-RA, has previously been reported to be associated with many serious risks, including gait unsteadiness,14 increased traffic accidents after use,15,16 increased falls in community-based and skilled nursing facilityehomed elderly residents,2 increased falls in hospitalized patients,17 amnestic sleeprelated eating,18,19 sleep driving,19 amnestic sleep-related sex acts, and other complex sleeprelated behaviors.20 The association with unusual behaviors has garnered much press, perhaps because some of the behaviors seem so colorful. However, there may be even more serious risks. To review, insomnia concerns are common. Cognitive behavioral therapy is a safe and effective therapy, but because it is often unavailable, hypnotic use is increasing. An increasing number of Americans and others worldwide use hypnotic drugs, and experience with this class of drugs is making it increasingly apparent that they are not as safe as originally perceived. These hypnotic drugs increase the risk of serious injury by up to 60% and the risk of an inpatient falling by a factor of 4 to 6, and they double the risks of motor vehicular accidents (especially among women).21 In view of these problems, what should physicians, public health policy makers, and patients do? Physicians and patients must be aware that zolpidem (and other hypnotics) carry major risks of harm, particularly if not used correctly. In many cases, insomnia may be prevented or improved by attention to lifestyle and sleep habits.10 Obtaining an accurate diagnosis of the causes of insomnia, expanded use of sleep hygiene coaching (providing general guidelines about diet and exercise; avoidance of caffeine,
May 2014;89(5):579-582
n
http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org
EDITORIAL
nicotine, and alcohol; attention to environmental factors that may promote or interfere with sleep; and adherence to salutary sleep schedules), and CBT should at least be considered before hypnotics. In medical settings that do not have access to in-person CBT, patients should still consider the use of proven online CBT methods,22-24 and forward-thinking health care systems should find ways to provide CBT because it is cost-effective and safe.25 Before considering a hypnotic drug, a careful riskbenefit assessment should be performed for each patient. Is the patient already at increased risk for falling or serious injury when falling? Is the patient capable of adhering to the bestpractice recommendations for use? When zolpidem (or another hypnotic) is prescribed, the minimal effective dose should be used for the minimal required time, patients should not use alcohol or other sedatives concurrently, they should take the medication only immediately before going to bed to sleep, and they should allow the specified time to sleep before awakening. Public health policy makers must take steps to help increase the availability of information to patients about the importance of sleep health, healthy sleep habits, and the effectiveness of CBT. Such measures might include increased education and training about CBT for physicians, advanced practice nurses, and physician assistants and incentives that increase patient access to other professionals who can provide CBT. The new National Healthy Sleep Awareness Project aims to improve sleep health policies, educate patients about behavior changes that can lead to improved sleep health and quality of life, and improve the quality, delivery, and use of clinical and other services to address the management and prevention of sleep disorders.26 This joint project of the American Academy of Sleep Medicine, the Sleep Research Society, and the Centers for Disease Control and Prevention is just an example of the type of collaborative effort required to tackle this public health issue, and programs like these need augmented and ongoing funding. 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. We need to be wary of the sirens of sleep. Mayo Clin Proc. n May 2014;89(5):579-582 www.mayoclinicproceedings.org
n
Timothy I. Morgenthaler, MD Mayo Clinic Center for Sleep Medicine Division of Pulmonary and Critical Care Medicine Mayo Clinic Rochester, MN Correspondence: Address to Timothy I. Morgenthaler, MD, Mayo Clinic Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]).
REFERENCES 1. Lai M-M, Lin C-C, Lin C-C, Liu C-S, Li T-C, Kao C-H. Longterm use of zolpidem increases the risk of major injury: a population-based cohort study. Mayo Clin Proc. 2014;89(5): 589-594. 2. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Zolpidem use and hip fractures in older people. J Am Geriatr Soc. 2001;49(12): 1685-1690. 3. Institute of Medicine (US) Committee on Sleep Medicine and Research. In: Colten HR, Altevogt BM, eds. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academies Press; 2006. 4. Bertisch SM, Herzig SJ, Winkelman JW, Buettner C. National use of prescription medications for insomnia: NHANES 1999-2010. Sleep. 2014;37(2):343-349. 5. Buscemi N, Vandermeer B, Friesen C, et al; University of Alberta Evidence-based Practice Center, United States; Agency for Healthcare Research and Quality. Manifestations and Management of Chronic Insomnia in Adults. Rockville, MD: Agency for Healthcare Research and Quality; 2005:Evidence Report/Technology Assessment 125. AHRQ Publication 05E021-2. 6. Budhiraja R. Insomnia in chronic obstructive pulmonary disease: breathless and sleepless [editorial]. Sleep Med. 2013;14(12): 1233-1234. 7. Omachi TA, Blanc PD, Claman DM, et al. Disturbed sleep among COPD patients is longitudinally associated with mortality and adverse COPD outcomes. Sleep Med. 2012;13(5): 476-483. 8. Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I. Sleep. 1999;22(suppl 2):S347-S353. 9. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep. 1998;21(3):235-238. 10. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update; an American Academy of Sleep Medicine report. Sleep. 2006;29(11):1415-1419. 11. Moloney ME, Konrad TR, Zimmer CR. The medicalization of sleeplessness: a public health concern. Am J Public Health. 2011;101(8):1429-1433. 12. Saul S. F.D.A. warns of sleeping pills’ strange effects. New York Times website. http://www.nytimes.com/2007/03/15/business/ 15drug.ready.html?pagewanted¼all&_r¼0#. Published March 17, 2007. Accessed February 18, 2014. 13. Hajak G, Müller WE, Wittchen HU, Pittrow D, Kirch W. Abuse and dependence potential for the nonbenzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addiction. 2003; 98(10):1371-1378. 14. Avidan AY, Fries BE, James ML, Szafara KL, Wright GT, Chervin RD. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc. 2005;53(6):955-962. 15. Yang YH, Lai JN, Lee CH, Wang JD, Chen PC. Increased risk of hospitalization related to motor vehicle accidents among
http://dx.doi.org/10.1016/j.mayocp.2014.03.006
581
MAYO CLINIC PROCEEDINGS
16.
17.
18. 19.
20.
21. 22.
582
people taking zolpidem: a case-crossover study. J Epidemiol. 2011;21(1):37-43. Farkas RH, Unger EF, Temple R. Zolpidem and driving impairmentdidentifying persons at risk. N Engl J Med. 2013;369(8): 689-691. Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6. Morgenthaler TI, Silber MH. Amnestic sleep-related eating disorder associated with zolpidem. Sleep Med. 2002;3(4):323-327. Poceta JS. Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series. J Clin Sleep Med. 2011;7(6):632-638. Dolder CR, Nelson MH. Hypnosedative-induced complex behaviours : incidence, mechanisms and management. CNS Drugs. 2008;22(12):1021-1036. Gunja N. In the Zzz zone: the effects of Z-drugs on human performance and driving. J Med Toxicol. 2013;9(2):163-171. Espie CA, Fleming L, Cassidy J, et al. Randomized controlled clinical effectiveness trial of cognitive behavior therapy
Mayo Clin Proc.
n
23.
24.
25.
26.
compared with treatment as usual for persistent insomnia in patients with cancer [published correction appears in J Clin Oncol. 2010;28(19):3205]. J Clin Oncol. 2008;26(28): 4651-4658. Holmqvist M, Vincent N, Walsh K. Web- vs. telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Med. 2014;15(2):187-195. Thorndike FP, Ritterband LM, Gonder-Frederick LA, Lord HR, Ingersoll KS, Morin CM. A randomized controlled trial of an Internet intervention for adults with insomnia: effects on comorbid psychological and fatigue symptoms. J Clin Psychol. 2013;69(10):1078-1093. McCrae CS, Bramoweth AD, Williams J, Roth A, Mosti C. Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs. J Clin Sleep Med. 2014; 10(2):127-135. Heffron T. Promoting healthy sleep with the CDC. American Academy of Sleep Medicine website. http://www.sleepeducation. com/news/2013/11/14/promoting-healthy-sleep-with-the-cdc. Published November 14, 2013. Accessed February 23, 2014.
May 2014;89(5):579-582
n
http://dx.doi.org/10.1016/j.mayocp.2014.03.006 www.mayoclinicproceedings.org
