David Gardner, BSc Pharm, MSc CH&E, PharmD Professor, Department of Psychiatry & College of Pharmacy

Transcription

1 David Gardner, BSc Pharm, MSc CH&E, PharmD Professor, Department of Psychiatry & College of Pharmacy It s no dream. Sleep well without sleeping pills.

2 Outline Baby boomers & beyond: medication use Deprescribing Sleeping pills benefit:risk Sleep well without sleeping pills

3 Why take medications? Necessary for health Improving symptoms Managing chronic conditions (e.g. diabetes, high blood pressure, chronic pain) Prolonging life expectancy 3

4 As we get older We often need to take more medications to manage chronic conditions The benefits and risks of medications may change 4

5 As we get older The brain becomes more sensitive to drug effects Medications stay longer in our body less muscle more body fat liver and kidneys not as efficient as when we were younger Higher concentrations of medications body contains less water & muscle 5

6 Report 2018

7 Medication use in Canadians 65+

8 Medication use in Canadians 65+

9 Medication side effects can be serious, resulting in hospitalizations If 65+ taking the following number of medication classes: Probability of being hospitalized due to adverse effects in 2016 was: in in in in 35

10 Today s new terms: 1. DEPRESCRIBING 2. POTENTIALLY INAPPROPRIATE MEDICATIONS (PIMS)

11 Deprescribe Reducing and stopping medications to improve health and reduce adverse effect burden and risk. Potentially Inappropriate Medications Identified as a medication with high risk for harm, especially in older adults, when safer management alternatives exist.

12 PIM examples Chronic use of anti-inflammatory medications such as ibuprofen or naproxen (non-steroidal anti-inflammatory drugs or NSAIDs) Antipsychotic medication when used as a sleeping pill or for dementia (e.g. quetiapine/seroquel, risperidone/risperdal ) Long-acting sulfonylureas (type-2 diabetes medications) (e.g. glyburide/diabeta ) Sleeping pills (e.g. alprazolam/xanax, zolpidem/sublinox ) Stomach pills for more than 8 weeks in acid reflux disease : proton-pump inhibitors (e.g. pantoprazole/pantoloc ) 12

13 Potentially Inappropriate Medications (PIMs) Canadians 65+ who take at least one PIM Morgan et al CMAJ Open; 4: E346-E51. 13

14 How effective are sleeping pills?

15 22 7 Z-drug -42 Placebo -20 Huevo-Medina et al. BMJ 2012 Change in time to fall asleep (min.)

16 14 Placebo +35 Z-drug +49 Huevo-Medina et al. BMJ 2012 Increase in total sleep time (min.)

17 Drug-drug interaction fact When opioids are used with sleeping pills, the risk of death increases. New York Times U.S. data: What fraction of deaths involving opioids in people 65+ also included sleeping pills? ~2/3rds Humphries. NEJM Feb 22,

18 THE TRUE COST OF SEDATIVE-HYPNOTIC USE

19 How safe are sleeping pills? Safety with other prescription medications, cough & cold remedies, alcohol, pain killers?

20 How safe are sleeping pills? Risk for falls, injuries, pneumonia,

21 How safe are sleeping pills? Worries, social withdrawal, isolation, loneliness Risky driving, automobile accidents, loss of independence

22 How safe are sleeping pills? Memory problems, cognitive impairment Cognitive decline

23 How safe are sleeping pills? The vicious cycle of medication use, dependence, and withdrawal

24 Proportion of seniors who are chronic users of benzodiazepines (& 4-year trend) B.C. 7% 8.6% Alta. 1.2% 15.8% 12% Man. 0.5% 15.7% 13% 1.0% Sask. 5% 5.3% 1.1% Chronic users: one or more claims for a benzodiazepine or other related drug (i.e., z-drug) in a given year, totalling at least 90 continuous supply days, without a gap in supply of at least 30 days Ont. 7% 8.7% 1.9% Canada 10.4% 1.5% Qc. 21%* N.B. 25% P.E.I 8% 25.1% 0.9% N.L. 21% 20.9% 1.3% N.S. 15% 16.4% 0.5% 58% above Canadian avg. Source: Canadian Institute for Health Information *Self report (Qc.)

25 The cost of falls 1/3 rd of fall-related hospitalizations in people 65+ involve hip fractures Source: CIHI 2014 Preventing Falls: From Evidence to Improvement in Canadian Health Care.

26 Population Attributive Risk of Benzodiazapines for Injurious Falls resulting in hospitalization Injurious falls in 85+ yo: BZDs account for >30% (men) and >40% (women) Injurious falls in year olds: BZDs account for ~5% (men) to ~10% (women) Panneman MJ et al. Drugs Aging. 2003

27 to reduce the potentially inappropriate use of sedative-hypnotics

28 American College of Physicians 2016 ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence) European Sleep Research Society 2017 CBT-I is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if CBT-I is not effective or not available.

29 Empower brochure

30 EMPOWER Tannenbaum et al. JAMA Intern Med 2014 Patients Initial invitation Design ~75 yo, 10 meds/day BZRA ~10 yrs Use: insomnia 60%; anxiety 50% Pharmacists: letter followed by phone call Referral to study team if interested. In-home meeting and consent. Cluster RCT (30 pharmacies) N 303 Intervention Outcomes Booklet (by mail) 6 mo. d/c (>3 mo. no BZRA) 6 mo. dose reduction or d/c

31 Direct Patient Education: BZD use months Intervention Usual care D/C BZD 27% 4.5% D/C & dose reduction BZD 38% 11% Tannenbaum et al. JAMA Intern Med 2014

32 You May Be at Risk EMPOWER brochure 8 page booklet Self-efficacy theory Components Self assessment of risks Education: BZRA harms Create cognitive dissonance Stories: augment self-efficacy Effective alternative Guidance: tapering

33 mysleepwell.ca It s no dream. Sleep well without sleeping pills. mysleepwell.ca

34 THERAPIST depression Insomnia and pain ONLINE older adults adults menopause fibromyalgia adolescents cancer BOOK stop hypnotics anxiety APP

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37 Go! To Sleep mysleepwell.ca 37

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41 Booklet 1 How To Get Your Sleep Back Booklet 2 How to Stop Sleeping Pills

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43 mysleepwell.ca

44 What can you do? Educate yourself about what medications you are taking and why. Engage in a discussion with your health care provider about deprescribing options and alternate therapies. Spread the word about deprescribing to friends and family, advocacy groups and government representatives. Ask questions, stay informed, be proactive, and participate in making smart choices. 44

45 Resources Download information on how you can stop certain medications at deprescribingnetwork.ca *Also available in French 45

46 Discussion It s no dream. Sleep well without sleeping pills.