Most medical organizations recommend against the use of benzodiazepine use for the treatment of insomnia, especially in the elderly. However, the percentage of the adult population on benzos increase with age: 7.5% in adults ages 51-64; 9% in adults over 65. Alternative therapies for insomnia, including online CBT, require more commitment than taking a medication so many patients opt for medication. This project aims to increase awareness of benzodiazepine use for insomnia and provide support for nonpharmacological therapies.https://scholarworks.uvm.edu/fmclerk/1380/thumbnail.jp

Pyon, UnChan

English

UVM ScholarWorks

University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2019Reducing Benzodiazepine Use for the Treatment ofInsomnia and Supporting NonpharmacologicalTherapiesUnChan PyonFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Medical Education Commons, and the Primary Care CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationPyon, UnChan, "Reducing Benzodiazepine Use for the Treatment of Insomnia and Supporting Nonpharmacological Therapies"(2019). Family Medicine Clerkship Student Projects. 323.https://scholarworks.uvm.edu/fmclerk/323REDUCING BENZODIAZEPINE USE FOR THE TREATMENT OF INSOMNIA AND SUPPORTING NONPHARMACOLOGICAL THERAPIESUNCHAN PYONFAMILY MEDICINE ROTATION 6, JANUARY 2018PROJECT MENTORS: DR. ANUREET GILL, MD; EMILY FRITZ, LCSWPROBLEM IDENTIFICATION▪ The number of patients who fill out a benzodiazepine prescription has increased from 4.1% to 5.6% between 1996 and 2013 – 2.5% annual increase [1]▪ Benzodiazepines are commonly used for the treatment of insomnia▪ Insomnia accounts for 5.5 million primary care office visits every year [4]▪ Among the elderly (age >65), 42% report difficulty falling and staying asleep. [3]▪ The American Geriatrics Society, The American Academy of Sleep Medicine, and the American Academy of Family Physicians all recommend against benzodiazepine use for insomnia, especially in the elderly [4]▪ However, the use of benzodiazepines increase with age: 3% of adults ages 18-34; 7.5% of adults ages 51-64; 9% in adults ages > 65. [5]▪ Furthermore, one study showed that there was a significant discord in what elderly patients and physicians believed in the risks and benefits of benzodiazepines for insomnia treatment: [3]▪ Elderly patients believed there were more benefits and less risks than what their physicians believed.PROBLEM IDENTIFICATION (DANBURY)▪ The Primary Care Clinic in Danbury is currently working on a benzodiazepine protocol in order to provide guidelines for providers to take most of their patients off benzodiazepines, in response to this issue.▪ A free online CBT training is offered as an alternative treatment for insomnia over benzodiazepines.▪ However, many barriers to the online CBT training exist: ▪ Patients find it hard to sit through long videos that cannot be skipped, rewound, or reviewed▪ There is a lack of awareness of the online CBT training, the adverse effects of benzodiazepines, and current guidelines recommending against benzodiazepines▪ No formal follow-up with patients on their online CBT training▪ Discussions with patients at Danbury Primary Care revealed a surprising low awareness to the adverse effects of benzodiazepines and current guidelines for insomnia treatment.PUBLIC HEALTH COST▪ It was estimated that the economic cost of insomnia was $30-35 billion per year in treatment and indirect costs including doctor’s visits, prescriptions, accidental risk, and lost workplace productivity. [7]▪ One study showed, out of 17,558 patients on benzodiazepines (9,304 of whom were over 59 years old), 1,352 patients suffered 297 injuries which led to hospital admissions, and 2,977 injuries leading to doctor’s visits. [2]▪ Injuries were sustained while on a benzodiazepine.▪ The total cost of these visits amounted to $3.3 million in medical bills.▪ Benzodiazepine overdose death rates increased from 0.58 per 100,000 adults to 3.07 per 100,000 adults between 1996 to 2013 – 430% increase. [1]▪ Discussions with patients at Danbury Primary Care, revealed that costs of benzos for patients were estimated to be about $300 annually.COMMUNITY PERSPECTIVE ON ISSUE AND SUPPORT▪ Patients often use benzos as a more convenient solution to their insomnia than committing to working with an online CBT. Also, patients are often unaware of the recommendations against benzos for insomnia.▪ “Patients, especially elderly patients, rely on benzos as a quick fix for their insomnia”▪ “Increasing awareness on the current recommendations against benzodiazepines use for insomnia in an important community health issue”Emily Fritz, LCSW▪ Patients are not consistently given CBT information, are not followed up on their effectiveness, and often find the training tedious and inconvenient. Also, patients can’t skip, fast forward, rewind, or review the training videos, making it time consuming and not user friendly.▪ “We do give out information for the online CBT website, but not consistently. We also do not have a formal way of following up on patients”▪ “There are barriers to the CBT training for patients because the videos can be long and tedious. I myself can’t find the time to sit down and go through all the videos.”Lisa Mello, LPNINTERVENTION AND METHODOLOGY▪ In order to increase the awareness of the current guidelines for insomnia treatment, a patient information sheet was created to be given to patients being treated with benzodiazepines for insomnia.▪ A meta-analysis showed that cognitive behavioral therapy for insomnia was an effective treatment for patients with insomnia. [5]▪ It is imperative that patients put in the effort to initiate CBT as a first-line treatment for insomnia.▪ However, the online CBT training is tedious, long, and does not provide a user friendly review of the material.▪ A handout providing a concise, aesthetically pleasing, easy to read, and informative summary of the online CBT was created to prime patients to the training and to serve as a review reference.▪ Visually engaging material was made using variable typography, implementation of free license vectors and images, and various font types.RESPONSE/RESULTS TO THE INTERVENTION▪ Response to the handouts were positive.▪ “You did an excellent summary of the CBT online, great work!”▪ “Nicely done and love the pics.”Emily Fritz, LCSW▪ “It’s a great idea to make a summary of the online CBT training which many patients have trouble finding the time for.”Lisa Mello, LPN▪ An initial evaluation on the effectiveness of the handouts were implemented by performing brief 2-question surveys on a limited number of insomnia patients▪ Two participants changed their perspectives on benzos after reading the handout: Agree to slightly disagree; Agree to disagree▪ The likelihood of these participants to consider alternative therapies increased 2 points on a 10 point scale▪ The likelihood of completing the CBT training increased 2 points▪ The likelihood of implementing non-pharmacological therapies for insomnia increased by 2.5 points▪ These participants rated the CBT summary handout an average of 9.5/10 in helpfulness.EVALUATION OF EFFECTIVENESS AND LIMITATIONS▪ A more thorough evaluation of the effectiveness of the intervention can be implemented by increasing the sample size of insomnia patients surveyed.▪ Medical students or any of the office staff will perform quick interviews asking 2-question surveys before and after the insomnia patients read the handouts to assess the effectiveness of the handouts in increasing awareness and providing a helpful summary of the CBT training.▪ The data collected from the surveys can be compiled and analyzed to assess how effective the handouts were in changing patients’ perspective on benzos for insomnia and in motivating patients to use non-pharmacological therapies for insomnia.▪ Limitations:▪ There was not enough time during the clerkship to collect data from surveys to assess the effectiveness of the intervention.▪ The sample size in the initial evaluation was only two participants.▪ There was a small population of insomnia patients at Danbury Primary Care, so it is difficult to create an adequate sample size.▪ The limited time during the office visit makes the provider less likely to conduct the survey and review the handout.RECOMMENDATIONS FOR FUTURE INTERVENTIONS/PROJECTS▪ Future medical students and staff can review these handouts with patients and educate them on benzodiazepine use. They can also collect data on its effectiveness using the surveys implemented.▪ There are additional online CBT training offered for depression and anxiety which are equally long, tedious, and inconvenient. ▪ Future medical students can create similar user-friendly, concise, and visually pleasing summaries of these therapies to serve as a primer and review sheet for patients. Patients should also be encouraged to use these therapies over pharmacologic therapies.▪ Similar surveys can be created and implemented to assess their effectiveness.▪ Furthermore, there is a lack of follow-up on the completion of these online CBT options. An intervention to formally follow-up and assess the effectiveness and compliance of the online CBT will be another beneficial intervention for insomnia treatment.REFERENCES1. Bachhuber, Marcus A. MD; Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013.2. French, Dustin D.; Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs, Advances in Patient Safety: From Research to Implementation (Volume 1: rResearch Findings)3. Mah, Leevin; Long term benzodiazepine use for insomnia in patients over the age of 60: discordance of patient and physician perceptions; BMC Fam Prac. 2002; 3:94. Matheson, Eric, MD; Insomnia: Pharmacologic Therapy; Am Fam Physician. 2017 Jul 1;96(1):29-355. Olfson, Mark, MD; Benzodiazepine Use in the United States; JAMA Psychiatry; Feb 2015, Vol 72, Number 26. Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D.; Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(3):191–204.7. Walsh JK, Engelhardt CL; The direct economic costs of insomnia in the United States for 1995. Sleep. 1999 May 1;22 Suppl 2:S386-83INFORMED CONSENTThank you for agreeing to be interviewed. This project is a requirement for the Family Medicine clerkship. It will be stored on the Dana Library ScholarWorks website. Your name will be attached to your interview and you may be cited directly or indirectly in subsequent unpublished or published work. The interviewer affirms that he/she has explained the nature and purpose of this project. The interviewee affirms that he/she has consented to this interview. Yes _X_ / No __ If not consenting as above: please add the interviewee names here for the department of Family Medicine information only. Name:Emily Fritz, LCSWLisa Mello, LPN

Reducing Benzodiazepine Use for the Treatment of Insomnia and Supporting Nonpharmacological Therapies

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Reducing Benzodiazepine Use for the Treatment of Insomnia and Supporting Nonpharmacological Therapies

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