An article published Feb. 27, 2012, in the British Medical Journal titled Hypnotics’ Association with Mortality or Cancer: A Matched Cohort Study is something we should know about for a few reasons. First, many of us take some form of sedative hypnotic before night shifts and, second, it’s been in the news. Your patients are going to want to know what to do.
Explore This IssueACEP News: Vol 31 – No 04 – April 2012
This was a population-based study that found those prescribed sedative hypnotics (most commonly zolpidem and temazepam) for sleep issues had a greater than threefold increase of death during the study period as well as an increased risk for cancer (bmjopen.bmj.com/content/2/1/e000850.full.pdf+html).
When I first saw this study, my eyes just about popped out of my head. My first job out of residency was all nights and I could never fall asleep before shifts, so by the fourth night in a row, I was really tired. Then I took a zolpidem at 5 p.m., woke up at 10 p.m., and it was night shift 2.0. Wide awake and ready to roll. It was like a cold glass of water on a hot summer day. But just as the Joe Jackson song goes, everything, it seems, gives you cancer.
This paper suggests a correlation between death/cancer and sedative hypnotics prescribed for sleep, but the real question is whether these drugs were directly responsible for the outcome or a marker for higher likelihood of underlying disease.
Were the insomniacs just sicker to start with? They were compared to a cohort with similar demographics and problem list comorbidities who were followed in the same clinics. The main body of the study says that there were not significant differences between the two groups but, the supplemental data, which is several mouse clicks away, shows that that is not the case. The prescription group had significantly higher incidence of prior disease (including coronary artery disease, chronic kidney disease, asthma, obesity, GERD, etc.). …
Death: There’s the obvious answer that [sleep drugs] impair thinking. If used during activities such as driving, or mixed with other meds or alcohol, [they] could lead to death. They may also worsen sleep apnea, which in turn could exacerbate other underlying comorbidities. Cause of death was not given in the study, so one can only surmise. I doubt there will be a controlled double-blinded trial to see if they directly kill people.
Cancer: Many factors may be at play with malignancy. Zolpidem increases risk of GERD, which increases risk of Barrett’s esophagus, which can lead to esophageal cancer. But that is a stretch. Lymphoma, lung, colon, and prostate cancer were also increased with the hazard ratio for sedative hypnotics being greater than that of smoking. It may be, however, that patients on these meds were also more likely to have more medical care and disease surveillance (detection bias).