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Study Suggests Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans

BACKGROUND:
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. However, there have been growing concerns associated with its use, such as higher risk of falls, adverse drug reactions, dependence, and mortality. In addition, clinically significant drug interactions with benzodiazepines are associated with increased hospitalizations. In 2013, these concerns prompted the FDA to recommend cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men, resulting in 50% higher serum levels. In line with FDA guidelines, VA's national Pharmacy Benefits Management service issued a similar directive. This study examined prescribing patterns among all VA patients who received zolpidem (n=500,332; men=441,734; women=58,598) from FY2012-FY2016. Additionally, investigators examined a random 10% sample of patients who did not receive zolpidem (n=631,449). Using VA data, investigators also assessed sociodemographics, marital status, medication co-payment, fiscal year of zolpidem prescription, region of the country where the patient received care, and physical and mental health conditions that were shown previously to be associated with zolpidem use.

FINDINGS:

  • There was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans.
  • In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%).
  • Patient characteristics associated with higher odds of receiving an inappropriate dose among women included younger age and the requirement of a co-payment. For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.

IMPLICATIONS:

  • Study findings suggest a quality of care problem with implications for patient safety that may be amenable to targeted interventions.

LIMITATIONS:

  • While national VA pharmacy data were used to account for zolpidem prescriptions, investigators did not include prescriptions obtained from Medicare Part D in Veterans with dual VA and Medicare Part D pharmacy use.

AUTHOR/FUNDING INFORMATION:
Dr. Jasuja is supported by an HSR&D Career Development Award and is part of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR).


PubMed Logo Jasuja G, Reisman J, Wiener R, Christopher M, and Rose A. Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration. The American Journal of Managed Care. March 2019;25(3):e58-65.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.