Pharmacotherapy for Chronic Insomnia: A Brief Survey of PCP Attitudes and Preferences

Purpose: To examine primary care professionals’ (PCP) attitudes and prescribing preferences toward hypnotic medications to treat chronic insomnia.
Methods: An online survey was sent to members of the Dartmouth CO-OP, a practice-based primary care research network in Maine, Vermont, and New Hampshire.  The survey begins with a case vignette of a 64-year old woman suffering from chronic insomnia.  Clinicians were then presented with eight questions about management of the patient and their attitudes toward prescribing medications, focusing on benzodiazepines/benzodiazepine receptor agonists (BDZ/BZRAs).
Results: 103 of 198 clinicians (52%) responded.  Regarding choice of medication for the case vignette, 81% of respondents preferred the off-label use of hypnotics such as trazodone or melatonin; 11% stated they would choose BDZs and 22% would choose BZRAs.  Strong majorities expressed that negative consequences would occur with use of BDZ/BZRAs, including tolerance (77%), dependence (68%), other side effects (53%), and addiction (51%). PCP preference for off- label prescribing was correlated to levels of concern about harms (addiction, dependence, tolerance, side effects) of BDZ/BZRAs as measured on a global medication risk score in this survey.  In addition, 14% of respondents felt that pharmacotherapy was not an appropriate therapeutic option for chronic insomnia in the case vignette.
Conclusion: Most of the clinicians surveyed acknowledged a legitimate role for hypnotic medications in chronic insomnia but expressed reservations toward BDZ/BZRAs despite their FDA-approval and proven efficacy.  There appears to be a gap between published guidelines for selection of sedative-hypnotic medications and PCP preferences.