Researchers have long known that parts of Atlantic Canada have the highest rates of chronic prescription sedative use among older adults in the country, with numbers roughly two to three times the Canadian average.
New Brunswick leads with the highest rates nationally with no decline in a decade, unlike the rest of Canada.
Dr. David Gardner, a professor in Dalhousie's Department of Psychiatry and College of Pharmacy, explored the phenomenon and recently outlined the findings of a clinical trial called YAWNS NB. The program, which stands for “Your Answers When Needing Sleep in New Brunswick,” tested the efficacy of receiving a written information package in the mail about sleep and sleeping pill use, including ways to reduce the reliance on them.
Pictured right: Dr. David Gardner (submitted photo)
Dr. Gardner presented the results, along with new epidemiological data on sedative use in the province, at public forums in Atlantic Canada. Some of the findings:
- The strongest predictor of prescription sedative use in New Brunswick is where you live. Heat maps show a distinct pattern of where use is highest in the province. While the rate is 1.5x higher in women than men broadly, the rate is five to six times higher in some New Brunswick communities compared with others, for both men and women. Among women 85 years and older (who are the group with the highest risk for falls & fractures), the proportion that take prescription sedatives chronically exceed 50 per cent in some parts of the province.
- New Brunswick datashow a 70 to 90 per cent increase in the risk of hospitalizations for falls, fractures, and hip fractures in association with the use of sedatives in older adults.
Dr. Gardner describes the findings of the research initiative and how preferred strategies, like Cognitive Behavioural Therapy for Insomnia (CBT-I) can be effective for those struggling with insomnia.
How do the rates of sedative use in this region compare to the rest of Canada?
Prior to releasing our most recent findings this fall, it was already known that Atlantic Canada had the highest rates of chronic prescription sedative use among older adults, roughly two to three times the Canadian average of about 8 per cent. New Brunswick ranked highest, followed by Newfoundland and Labrador and Nova Scotia. Interestingly, use of sedatives on P.E.I. is lower, close to the national average.
What did you discover about sedative use in Atlantic Canada in your research?
Our latest findings focus on New Brunswick. We completed YAWNS NB, an interventional study evaluating a direct-to-patient mailed package that shares information about sedatives and non-medication approaches to treat insomnia. The objectives were to reduce sedative use while improving sleep. Using linked health records, we then assessed the durability of the intervention's effects and, in parallel, conducted a province-wide study of sedative use among community-dwelling adults aged 65 and older.
We found that over one year, 36,480 of 171,639 individuals (21.3 per cent) took sedatives long-term. Rates were 55 per cent higher in women and 50 per cent higher in those aged 85 and older compared with ages 65 to 69. However, the strongest predictor was place of residence, with some regions showing several-fold higher use than others within the same age and sex groups.
Importantly, the Sleepwell mailed intervention did not lose its impact for our study participants after the trial ended. Dispensary data showed reduced sedative use during the six-month trial and further reductions over the following 12 months, a surprisingly durable effect for a low-effort, easily scalable intervention.
Why are sedative use rates so much higher in Atlantic Canada?
While it is a difficult question to answer, it seems unlikely to be explained by differences in rates of insomnia across the country or by differences in access to non-medication therapies. Most people are unfamiliar with CBT-I, the recommended first-line therapy for insomnia, regardless of where you live in Canada.
It is more likely explained based on sociological norms, medical practice, and public expectations of how to manage insomnia. In places where sedative use is prevalent, it becomes normalized and routinized. Their use is further reinforced because of their pharmacological effects that cause withdrawal-related insomnia when abruptly stopping sedatives. Normalizing their use and the vicious cycle of reinforced use likely explains, in part, why some regions have very high rates of use compared to others.
What are the dangers associated with the overuse of sedatives?
Sedatives, when used short and long-term, carry well-documented risks, which vary from one type of sedative to the other. Considering all commonly used sedatives, we are concerned about next-day drowsiness, memory and concentration problems, falls and fractures, motor vehicle collisions, complex sleep behaviours, and dependence. We describe these and other concerns as well as how to safely reduce sedative use at Sleepwell (mysleepwell.ca).
Insomnia is often treated with sedatives without a clear plan. Medications meant for short-term relief are frequently continued for years, even though the risks increase with age and the benefits often fade. This makes it especially important to raise awareness of preferred, effective, short-term behavioural and psychological treatments that improve sleep long-term and reduce ongoing reliance on medication.
What can be done to address the overuse of sedatives in Atlantic Canada?
We developed Sleepwell (mysleepwell.ca) to increase awareness of CBT-I and reduce reliance on sleeping pills. Available are resources and recommendations for the public and health care professionals. We work with sleep experts and researchers across Canada and internationally to ensure our approaches reflect the best available evidence. Our work includes public education events, training for health-care professionals, and collaboration with physicians, pharmacists, other health care professionals, and government and other organizational partners. Ultimately, addressing the overuse of sedatives in Atlantic Canada requires shifting insomnia care toward safer, evidence-based non-medication therapy.