These slides are the intellectual property of Dr Hugh Selsick and must not be reproduced

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2 AIMS - SAFETY BE AWARE OF THE CONTROVERSY AROUND: WHETHER HYPNOTICS INCREASE MORTALITY. WHETHER HYPNOTICS INCREASE FALLS. WHETHER THEY ARE ADDICTIVE. UNDERSTAND WHICH HYPNOTICS MAY INCREASE THE RISKS OF DRIVING ACCIDENTS. UNDERSTAND THE RISKS OF OVERDOSE.

3 DO HYPNOTICS KILL? NUMEROUS STUDIES DATING BACK AT LEAST 35 YEARS HAVE FOUND AN ASSOCIATION BETWEEN HYPNOTIC USE AND MORTALITY (E.G. KRIPKE, 2012). THERE IS DISAGREEMENT ABOUT WHETHER OCCASIONAL USE IS ASSOCIATED WITH INCREASED MORTALITY (KRIPKE, 2012) OR NOT (MALLON, 2012). THE ASSOCIATION MAY DISAPPEAR WHEN COMORBIDITIES ARE CONTROLLED FOR (RUMBLE, 1992). ALL STUDIES HAVE A NUMBER OF UNMEASURED POTENTIAL CONFOUNDERS WHICH ARE PROVEN TO INCREASE MORTALITY.

4 HYPNOTIC LEADS TO DEATH Hypnotic Death Insomnia

5 INSOMNIA LEADS TO DEATH Hypnotic Death Insomnia

6 INSOMNIA & HYPNOTIC ARE MARKERS Insomnia Hypnotic Fatal illness prodrome

7 INSOMNIA AND DEATH HAVE COMMON CAUSE Hypnotic Common risk factor Insomnia and fatal illness

8 PRACTICE POINTS IT IS RESPONSIBLE TO TELL PATIENTS ABOUT THE ASSOCIATION. IT IS ALSO RESPONSIBLE TO EXPLAIN THAT THIS DOES NOT CONFIRM CAUSATION. PATIENTS ARE USUALLY ABLE TO WEIGH UP THE POTENTIAL RISKS AND BENEFITS AND ARRIVE AT A REASONED, RATIONAL DECISION.

9 FALLS IT IS COMMONLY ASSUMED THAT HYPNOTICS INCREASE THE RISK OF FALLS IN THE ELDERLY. ALL PSYCHOTROPICS ARE ASSOCIATED WITH INCREASED RISK OF FALLS. ANTIDEPRESSANTS SEEM TO HAVE THE HIGHEST RISK. STUDIES HAVE NOT PROVEN A CAUSATIVE RELATIONSHIP (BLIWISE, 2011). SLEEP DISRUPTION IMPACTS ON OBJECTIVE BALANCE TESTS (STUDENSKI, 2010). THERE IS FAIRLY ROBUST EVIDENCE THAT INSOMNIA ITSELF IS A MAJOR RISK FACTOR FOR FALLS (STUDENSKI, 2010)

10 PRACTICE POINTS IT IS LIKELY THAT HYPNOTICS INCREASE THE RISK OF FALLS, ESPECIALLY IN INDEPENDENT LIVING ADULTS. IT IS LIKELY THAT HAVING INSOMNIA AND WONDERING AROUND AT NIGHT INCREASES THE RISK OF FALLS. YOUR JOB IS TO WEIGH UP THESE TWO RISKS AND CHOOSE THE COURSE OF ACTION THAT LEADS TO LEAST RISK FOR EACH INDIVIDUAL PATIENT. IF YOU DECIDE TO PRESCRIBE MEDICATION BE SURE IT WORKS! WONDERING AROUND AT NIGHT IN A SEDATED STATE IS SURELY THE GREATEST RISK OF ALL.

11 ABUSE AND ADDICTION THERE IS NO QUESTION THAT HYPNOTICS CAN BE ABUSED (VICTORRI-VIGNEAU, 2007). HOWEVER, THE PREVALENCE OF ABUSE IS VERY UNCERTAIN. THERE IS A GREAT DEAL OF ANXIETY AMONGST DOCTORS AND PATIENTS ABOUT THE ADDICTIVE POTENTIAL OF HYPNOTICS. HOWEVER, ADDICTION IS NOT INEVITABLE; INDEED IT IS NOT AT ALL COMMON (WILSON, 2010). MOST PATIENTS WHO USE HYPNOTICS DO NOT ESCALATE THE DOSE (WILSON, 2010) AND USE THEM IN AN APPROPRIATE WAY.

12 PRACTICE POINTS LONG TERM USE OF HYPNOTICS IS MORE LIKELY TO BE A REFLECTION OF THE CHRONIC NATURE OF INSOMNIA THAN DEPENDENCE. HOWEVER, ALARM BELLS SHOULD RING IF THE PATIENT ESCALATES THE DOSE BEYOND THE BNF MAXIMUM, COMBINES IT WITH OTHER SEDATIVES OR USES IT DURING THE DAY.

13 DRIVING & HEAVY MACHINERY INSOMNIA PROBABLY INCREASES THE RISK OF CAR ACCIDENTS AND DEFINITELY INCREASES THE RISK OF INDUSTRIAL ACCIDENTS (LEGER, 2002; LAUGSAND, 2014). LONGER ACTING HYPNOTICS CAN IMPAIR DAYTIME PERFORMANCE INCLUDING DRIVING THE DAY AFTER (BALDWIN, 2013). MOST HYPNOTICS OTHER THAN ZALEPLON ARE LIKELY TO IMPAIR PERFORMANCE IF TAKEN TOO LATE AT NIGHT (VERMEEREN, 1998).

14 PRACTICE POINTS ALWAYS ASK IF PATIENTS DRIVE OR ENGAGE IN SAFETY CRITICAL WORK. IF SO AVOID ZOPICLONE, CLONAZEPAM ETC. AND RATHER USE ZOLPIDEM OR ZALEPLON. ADVISE PATIENTS NOT TO TAKE A FULL DOSE IN THE MIDDLE OF THE NIGHT (UNLESS USING ZALEPLON). ADVISE PATIENTS TO TAKE THEIR FIRST DOSE ON A NIGHT WHEN THEY AREN T GOING TO DRIVE ETC. THE NEXT DAY SO THEY KNOW HOW THEY RESPOND TO IT.

15 OVERDOSE THIS IS CLEARLY A RISK WITH MANY MEDICATIONS. FATAL OVERDOSES ARE RARE. MOST CASES OF FATAL OVERDOSE INVOLVE POLYPHARMACY OR ALCOHOL (SERFATY, 1993; KOSKI, 2006; MICHEL, 2007).

16 PRACTICE POINTS AVOID POLYPHARMACY IF POSSIBLE. BE ESPECIALLY CAUTIOUS IN PATIENTS WHO DRINK/USE DRUGS.

17 AIMS - EFFICACY UNDERSTAND: WHETHER THEY WORK. HOW LONG THEY WORK FOR. WHAT HAPPENS WHEN YOU STOP THEM.

18 DO HYPNOTICS WORK? Sleep onset latency These slides are the intellectual property of Dr Hugh Selsick and must not be reproduced Total sleep time Sleep efficiency Wake time after sleep onset Sleep quality PSG PSG PSG Selfrated Selfrated Selfrated Selfrated PSG Self-rated Benzos Z drugs (Wilson, 2010).

19 PRACTICE POINTS IF YOU AND THE PATIENT ARE SATISFIED THAT THE POTENTIAL BENEFITS OUTWEIGH THE RISKS THEN TRY A HYPNOTIC. ASK THE PATIENT IF IT S WORKING! THE SINGLE MOST IMPORTANT QUESTION TO ASK: DO YOU FEEL BETTER OR WORSE DURING THE DAY WHEN YOU TAKE THIS MEDICATION. IF IT DOESN T WORK THE PATIENT WILL STOP TAKING IT.

20 DO THEY WORK IN THE LONG TERM? These slides are the intellectual property of Dr Hugh Selsick and must not be reproduced (Roth, 2005).

21 PRACTICE POINTS IF YOU DON T HAVE AN ALTERNATIVE TREATMENT THEN THERE ARE TIMES WHEN LONG TERM HYPNOTIC USE MAY BE A NECESSARY AND EFFECTIVE TREATMENT. THERE IS MORE EVIDENCE FOR THE USE OF Z DRUGS IN THE LONG TERM THAN THE BENZO S.

22 DO THEY WORK WHEN YOU STOP TAKING THEM? IF INSOMNIA IS ACUTE AND TIME LIMITED THIS DOESN T REALLY MATTER. IF INSOMNIA IS CHRONIC THEN IT IS A VITAL QUESTION. ONCE THE MEDICATION IS DISCONTINUED THE EFFECT IS LOST (RIEMANN, 2008). WHEN THE DOCTOR DISCONTINUES THE MEDICATION THE PATIENT WILL EXPERIENCE A RECURRENCE OF SYMPTOMS AND WILL ASK FOR MORE. THIS IS USUALLY MISTAKEN FOR ADDICTION.

23 PRACTICE POINTS IN CHRONIC INSOMNIA A SHORT COURSE OF HYPNOTICS JUST TO RESET THE SLEEP CYCLE DOESN T WORK. IF YOU ARE TREATING CHRONIC INSOMNIA YOU NEED TO BE WILLING TO CONSIDER THE POSSIBILITY OF A LONG TERM HYPNOTIC. OR YOU NEED TO HAVE ACCESS TO AN ALTERNATIVE TREATMENT. AT PRESENT THE ONLY EFFECTIVE ALTERNATIVE TREATMENT AVAILABLE IS CBT FOR INSOMNIA AND EVEN THEN THE AVAILABILITY IS PATCHY.

24 CONCLUSION THERE IS STILL MUCH WE DON T KNOW ABOUT THE RISKS ASSOCIATED WITH HYPNOTICS. BUT WE DO KNOW A GREAT DEAL ABOUT THE RISKS OF INSOMNIA. ONE SHOULD WEIGH UP THE POTENTIAL RISKS OF HYPNOTICS WITH THE POTENTIAL RISKS OF INSOMNIA IN EACH INDIVIDUAL PATIENT AND MAKE A DECISION ON PRESCRIBING THAT TAKES INTO ACCOUNT THAT PATIENT S VALUES, MEDICAL AND PSYCHIATRIC COMORBIDITIES, OCCUPATION AND WISHES. WHEN PRESCRIBING THERE IS NO ONE SIZE FITS ALL APPROACH AND ONE SHOULD CHOOSE THE DRUG THAT IS LIKELY TO OFFER THE GREATEST BENEFIT WITH THE LOWEST RISK.

25 QUESTIONS? These slides are the intellectual property of Dr Hugh Selsick and must not be reproduced