Running head: HYPNOTICS 1

Hypnotics

Mallory M. Miner

Idaho State University

Abstract:
HYPNOTICS 2

Insomnia seems to be on the rise in the general adult population, which gives reason for concern.

Sleep is important and relevant for practitioners in primary care. In order to treat insomnia, a

primary care provider will use various pharmaceutical and non-pharmaceutical methods. Before

a hypnotic is prescribed, the cause of insomnia should be established. In general, hypnotics

should not be given routinely and for no longer than three consecutive weeks. Some major

concerns when prescribing hypnotics include tolerance and dependence. There are other

hypnotics and many medications that offer similar off label benefits. With varying factors such as

a sex, age, and socioeconomic status, it is important as a provider to address and be aware of

these themes in the clinical setting. Sleep hygiene is an important teaching tool in order to

improve sleep. Effective treatment can be given when all of these factors of the process are

considered.

Hypnotics
We all need sleep. According to the Center for Disease and Control (CDC) adults,

including the elderly, need 7-8 hours a day; sleep-related difficulties affect many people, and

there are many major sleep disorders, including insomnia, narcolepsy, restless leg syndrome, and

sleep apnea (2013, July 1). This paper will mostly focus on insomnia. While most primary care

providers are not specialists in sleep medicine, it is important to recognize when a patient may

need a sleep study or other pharmacologic agents to treat their disorder.

HYPNOTICS 3

Insomnia is an inability to initiate or maintain sleep and can result in functional

impairment throughout the day (CDC, 2013, July 1). As a primary care provider, before making a

new diagnosis of primary insomnia, one will need to rule out other potential causes, such as other

sleep disorders, side effects of medications, substance abuse, depression, or other previously

undetected illnesses. Providers may treat chronic insomnia with a combination of sedative-

hypnotic or sedating antidepressant medications, along with behavioral techniques to promote

regular sleep. Insufficient sleep has been linked to the development and management of a

number of chronic diseases and conditions, including diabetes, cardiovascular disease, obesity,

and depression (CDC, 2013, July 1).

According to the Center for Disease and Control About 70 million Americans suffer

from chronic sleep problems more than one-quarter of the U.S. population report occasionally

not getting enough sleep, while nearly 10% experience chronic insomnia (2013, July 1). The

CDC goes on to say that while people often consider sleep a passive activity, science has proven

otherwise, science proves getting enough sleep is essential. Sleep deprivation is associated with

many injuries, chronic diseases, mental illnesses, poor quality of life and well-being, increased

health care costs, and lost work productivity. Sleep problems are critically under-addressed

contributors to chronic conditions. The CDC concludes with, sufficient sleep is not a luxuryit

is a necessityand should be thought of as a vital sign of good health (2013, July 1).

Clinical Question
Sleep is important and relevant for practitioners/primary care providers. In this paper, I

would like to define insomnia, explain the different types, and offer a review of current clinical

trials and data. Throughout the paper, we will examine the various pharmaceutical and non-

pharmaceutical methods that primary care providers use to treat sleep disorders. We will look at

various options and consider their prescriptions and side effects. Primary care providers should
HYPNOTICS 4

address this in everyday practice by being familiar with the available options and knowing when

a hypnotic may need to be prescribed.

Background

When investigating possible treatment for insomnia, it may seem difficult to isolate the

best solution. Insomnia is primarily diagnosed by clinical evaluation using a thorough sleep

history which should cover specific insomnia complaints and areas such as pre-sleep conditions,

sleep-wake patterns, other sleep-related symptoms, and daytime consequences (Schutte-Rodin,

Broch, Buysse, Dorsey & Sateia, 2008). When prescribing a pharmacological treatment, the

provider must educate the patient on the treatment goals, safety and side effects, other treatment

options such as behavioral therapy, dosage, and rebound insomnia. Patients should have regular

follow up. This is because there is a high level of variability.

According to Waterfield, insomnia is any disturbance of normal sleep, difficultly in

initiating sleep and/or maintaining sleep. Insomnia can be primary or secondary. Primary

insomnia is sleep problems when there is no comorbidity. Whereas, secondary insomnia occurs

as a symptom associated with other conditions. Waterfield suggests that before a hypnotic is

prescribed the cause of insomnia should be established. Short term insomnia may last for a few

weeks and is often due to an emotional or medical problem. In general, hypnotics should not be

given routinely and for no longer than three weeks (Waterfield, 2010).

Waterfield mentions two major concerns in prescribing hypnotics: tolerance and

dependence. Tolerance is when more medication is needed to produce an effect. Dependence is

both physical and psychological and can result in withdrawal syndrome, which can cause

anxiety, nausea, perceptual changes, and rebound insomnia. As a primary care provider, it is

important to be aware of these trends and to look for the signs of tolerance and dependence.
It is important to realize there are other hypnotics and many medications that offer similar

off label benefits. Some of the other options include modified release melatonin which is used
HYPNOTICS 5

for short term primary insomnia in adults over the age of 55. Antihistamine products are

available over the counter for occasional insomnia; however, the use of hypnotics is not justified

to treat children (Waterfield, 2010).

Review of Current Clinical Trials data
In one study done in Sweden, it was found those who used hypnotics and were living

alone had considerably worse sleep quality as well as the shortest sleeping time than non-

hypnotic users and those who lived together. This study also found there was a major increase of

hypnotics and frequency of use in patients with increasing age. Interestingly enough, the

frequency of napping increased with a degree of dependence in all age groups and with

increasing age. The authors concluded that insomnia treated with hypnotics had not improved

sleep for older people.

Like it has been stated before, the authors found in this study that hypnotics are effective

as short-term treatment. They do recommend other non-pharmacological interventions, such as

psychological and behavioral therapies for treating older people with chronic insomnia (Hgg,

Houston, Elmsthl, Ekstrm, & Wann-Hansson, 2014). As primary care providers, it is vital to be

aware of these other therapies and not just give everyone who asks for one a hypnotic.

Another study investigated a 10-year trend in the incidences of insomnia symptoms,

cases, and agents. They used data from two representative surveys assessing identical insomnia

symptoms in an adult population. The first was conducted in 19992000, where N = 2001. The

other was conducted in 20092010, where N = 2000. They found women reported a higher

prevalence of insomnia than men. As a provider, this would be something to be aware of.
The study also provided researchers with the conclusion that age was positively

associated with the prevalence of nocturnal sleep problems and the use of hypnotic agents. This

would also be convenient to recognize when seeing patients. Finally, individuals with low

socioeconomic status reported a higher prevalence of several insomnia symptoms (Pallesen,

HYPNOTICS 6

Sivertsen, Nordhus, & Bjorvatn, 2014). With all of these varying factors such as a sex, age, and

socioeconomic status, it is important as a provider to address and be aware of these themes in the

clinical setting.
This study also pointed out that during the last couple of decades, there have been many

societal changes that have influenced sleep. Some of these include an expansion of television

broadcasts, an increase in nonstandard working hours, an increase in use of electronic devices,

including computers, smart phones, video games, among others, the establishment of a 24-hour

society, and an increase of the proportion of the population who are overweight or obese

(Pallesen, Sivertsen, Nordhus, & Bjorvatn, 2014). As providers, it is important to counsel

patients on ways to promote healthy sleep habits and patterns and not just write a prescription

and send them off.

The authors propose that more studies on the issue of secular trends in insomnia are

needed, especially as the numbers of previous studies are few. In addition, some of the studies

only focused on women and some only used global sleep questions that do not discriminate

between different insomnia symptoms. Finally, the authors offer the idea insomnia seems to be

on the rise in the general adult population, which gives reason for concern. Prevention of

insomnia and cost-effective interventions should receive higher priority in the future (Pallesen,

Sivertsen, Nordhus, & Bjorvatn, 2014).

Pharmaceuticals

Lunesta, Ambien, and Sonata, are popular hypnotic medications that are used to treat

sleep disorders. These are some hypnotics widely used by the elderly. Some symptoms include

excessive daytime sleepiness, depression, and anxiety (Jaussent, Ancelin, Berr, & Dauvilliers, et

al., 2013). In a study with 34,727 patients, with 76% on benzodiazepines, 39% on Z drugs, and

21% on other hypnotic drugs, it was found that hypnotic drugs were associated with an increased
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risk of death (Belknap, 2014). Those on hypnotics should be evaluated for potential drug to drug

interactions, such as occult sleep apnea, polypharmacy, alcohol or illicit drug use, chronic pain

and suicide. Belknap concludes patients with asthma or chronic obstructive pulmonary disease

may be at risk for hypoventilation and pneumonia.

Non-pharmaceuticals
In a study by Morgan, Dixon, Mathers, Thompson, & Tomeny orchestrated in 2003 it was

found that cognitive behavior therapy for insomnia is more cost effective than long-term

hypnotic drugs. In this study, there were 209 patients who used cognitive behavior therapy, and

at the three and six month follow up appointments, they reported interesting findings. For

example, they had significant reductions in sleep latency, significant improvements in sleep

efficiency, and significant reductions in the frequency of hypnotic drug use (Morgan, Dixon,

Mathers, Thompson, & Tomeny, 2003). The authors argue that in routine general practice

settings, psychological treatments for insomnia can improve sleep quality and reduce hypnotic

consumption at a favorable cost among long-term hypnotic users with chronic sleep difficulties

(Morgan, Dixon, Mathers, Thompson, & Tomeny, 2003).

Everyday Practice
Finally, as a primary care provider, it is important to screen your patients complaining of

having difficulties. Before a visit, it would be wise to advise patients to keep a diary of their

sleep habits for ten days prior to the visit and include: when you go to bed, when you go to sleep,

wake up, get out of bed, take naps, exercise, and when you consume alcohol/caffeinated

beverages. Sleep hygiene is an important teaching tool in order to improve sleep.

According to the CDC and the national sleep foundation, they recommend patients to: go

to bed at the same time each night and rise at the same time each morning; make sure your

bedroom is a quiet, dark, and relaxing environment, which is neither too hot nor too cold; make

sure your bed is comfortable and use it only for sleeping and not for other activities, such as

reading, watching TV, or listening to music. Remove all TVs, computers, and other gadgets from
HYPNOTICS 8

the bedroom, and, finally, avoid large meals before bedtime (2013, July 1). Once all of these non-

pharmacologic factors have been utilized, the provider may proceed to treat using various

pharmacologic methods.
Conclusions
In conclusion, despite the fact that during the last couple of decades there have been

many societal changes that have influenced sleep, there are medications such as hypnotics:

Lunesta, Ambien, and Sonata that can be used to treat sleep disorders. As a primary care

provider, one must be cautious when prescribing hypnotics and make sure that the cause of

insomnia is established. Also keep in mind that cognitive behavior therapy for insomnia is more

cost effective than long-term hypnotic drugs. And, finally, other non-pharmacological

interventions, such as psychological and behavioral therapies and sleep hygiene may be

beneficial to your patient population as well.

References
Belknap, S. M. (2014). In adults, use of anxiolytic or hypnotic drugs was associated with
increased risk for mortality. Annals Of Internal Medicine, 161(2), JC11.
Hgg, M., Houston, B., Elmsthl, S., Ekstrm, H., & Wann-Hansson, C. (2014). Sleep quality,
HYPNOTICS 9

use of hypnotics and sleeping habits in different age-groups among older people.
Scandinavian Journal Of Caring Sciences, 28(4), 842-851. doi:10.1111/scs.12119
Jaussent, I., Ancelin, M., Berr, C., Prs, K., Scali, J., Besset, A., & ... Dauvilliers, Y. (2013).
Hypnotics and mortality in an elderly general population: a 12-year prospective study.
BMC Medicine, 11(1), 1-11. doi:10.1186/1741-7015-11-212
Morgan, K., Dixon, S., Mathers, N., Thompson, J., & Tomeny, M. (2003). Psychological
treatment for insomnia in the management of long-term hypnotic drug use: a pragmatic
randomised controlled trial. The British Journal of General Practice, 53(497), 923928.
Pallesen, S., Sivertsen, B., Nordhus, I. H., & Bjorvatn, B. (2014). Original Article: A 10-year
trend of insomnia prevalence in the adult Norwegian population. Sleep Medicine, 15173-

179. doi:10.1016/j.sleep.2013.10.009
Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for
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