Middle-of-the-Night Hypnotic Use in a Large National Health Plan

Abstract

that are approved for nocturnal awakenings and/or prolonged wake time after nocturnal awakenings, all but one stipulate bedtime administration with middle-of-the-night use being explicitly disapproved to minimize risk of residual sedation. In other words, such bedtime hypnotics are designed to be preventative treatments for possible nocturnal awakenings rather than active treatments administered after nocturnal awakenings occur. The single hypnotic accepted by the FDA for as-needed MOTN Study Objectives: Although diffi culty maintaining sleep (DMS) is the most common nighttime insomnia symptom among US adults, many FDA-approved hypnotics have indications only for sleep onset, stipulating bedtime administration to offset residual sedation. Given the well-known self-medication tendencies of insomniacs, concern arises that maintenance insomniacs might be prone to self-administer their prescribed hypnotics middle-of-the-night (MOTN) after nocturnal awakenings, despite little effi cacy-safety data supporting such use. However, no US data characterize the actual population prevalence or correlates of MOTN hypnotic use. Methods: Telephone interviews assessed patterns of prescription hypnotic use in a national sample of 1,927 commercial health plan members (ages 18-64) receiving prescription hypnotics within 12 months of study. The Brief Insomnia Questionnaire assessed insomnia symptoms. Results: 20.2% of respondents reported MOTN hypnotic use, including 9.0% who sometimes used twice-per-night (once at bedtime plus once MOTN) and another 11.2% who sometimes used MOTN, but never twice-per-night. The remaining 79.8% used exclusively at bedtime. Among exclusive MOTN users, only 14.0% used MOTN on the advice of their physician (52.6% of those seen by sleep medicine specialists and 42.6% by psychiatrists vs. 5.2% to 13.6% seen by other physicians). MOTN use predictors included DMS being the most bothersome sleep problem, long duration of hypnotic use, and low frequency of DMS. Conclusions: One-fi fth of patients with prescription hypnotics used MOTN, only a minority on advice from their physicians. Since signifi cant next-day cognitive and psychomotor impairment is documented with off-label MOTN hypnotic use, prescribing physicians should question patients about unsupervised MOTN dosing. Keywords: Insomnia, sleep maintenance, hypnotics, middleof-the-night, dosing, medication adherence, prevalence Citation: Roth T; Berglund P; Shahly V; Shillington AC; Stephenson JJ; Kessler RC. Middle-of-the-night hypnotic use in a large national health plan. J Clin Sleep Med 2013;9(7):661-668.http://dx.doi.org/10.5664/jcsm.2832 S C I E N T I F I C I N V E S T I G A T I O N SI nsomnia is the most common nighttime sleep problem, and sleep maintenance insomnia the most common insomnia symptom both in the general population 1 and among adults with clinical insomnia. 2 An estimated one-fourth of all noninstitutionalized US civilians and two-thirds of US insomniacs report frequent sleep maintenance problems involving nocturnal awakenings and/or p...

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