Hypnotic Dependence May Predict Desire to Reduce Prescription Sleep Medication Use

Patients with insomnia who reported greater hypnotic dependence and actively sought CBTi were more likely to want to reduce the use of prescription hypnotics.

Among users and nonusers of prescription sleep medications (ie, hypnotics) who seek cognitive behavioral therapy for insomnia (CBTi), beliefs vary with respect to the necessity and potential hypnotic dependence linked to these agents. These are the findings of a study published in the Journal of Clinical Sleep Medicine.

Despite dissuasion on the part of many professional organizations on the prescribing of sleep medications, numerous middle-aged and older adults with insomnia continue to be treated with these agents.  The use of these drugs, including benzodiazepines,
“z-drugs” (eg, zolpidem, eszopiclone), and other sedating medications (eg, trazodone), is discouraged in this population, based on reports of hypnotic dependence and adverse events.

For the study, researchers sought to evaluate how views on prescription sleep medications differ between users and nonusers of these agents who are interested in CBT. They also looked at the possible predictors of patients’ interest in reducing their use of hypnotics. Prior analyses have recognized patient characteristics that are linked to the chronic use of hypnotics, including female sex, older age, and poor physical health.

Researchers obtained baseline data from the RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING; ClinicalTrials.gov Identifier: NCT03532282) in an effort to learn more about factors that impact patients’ interest in or ambivalence over reducing their use of prescription sleep agents.

[P]rescription sleep medication users endorsed stronger beliefs about the necessity of these medications and less concern about the consequences of use than non-users.

Since hypnotic dependence can complicate endeavors to discontinue the use of prescription sleep medications, knowledge on the extent and severity of this dependence in middle-aged and older adults is important. In fact, ambivalence regarding the use of these agents may actually increase an individual’s likelihood of resuming use prior to completion of a medication taper — particularly if a patient experiences symptoms of withdrawal.

Study participants comprised adults who were enrolled in the RESTING study — a 2-arm randomized, controlled trial with a “Hybrid Type 1 effectiveness-implementation design testing two strategies for delivering CBTI.”  The researchers of the current study used “RESTING study baseline measures that captured perceptions of sleep and sleep-related cognitions, mental health, physical health, and use of sleep medications.” All of the study participants were recruited from primary care clinics and the Stanford Research Repository. Baseline data were obtained from a total of 245 adults (mean age, 63 years; 74% women; 72% White; 63% married or with a common law partner; and 53% retired or unemployed) from the RESTING study.

Researchers found that users of prescription sleep medications exhibited significantly stronger beliefs about the need for sleep medications and less concern over possible harms associated with their use compared with nonusers (P <.01). Additionally, stronger dysfunctional sleep-associated cognitions were predictive of significantly greater beliefs about the need for and concern about the use of sleep medications (P <.01).                        

Increased severity of hypnotic dependence was associated with a significantly higher likelihood of a desire to reduce the use of sleep medications (odds ratio [OR], 1.73; 95% CI, 1.22-2.47; P =.002) and better mental health (OR, 2.23; 95% CI, 1.14-4.72;
P =.02). The researchers noted that sex, work status, and civil status were not statistically significant as independent predictors of this decision.

Civil status and mental health were significantly associated with patient medication goals (OR, 0.34; 95% CI, 0.16-0.75; P =.002) that individuals who did not have a current partner who supported the desire to reduce sleep medication use reported better mental health than those who did not feel this way.

The current study has several limitations, including selection bias, since the participants were actively seeking the use of CBTi. Further, although the current study did not reveal any significant demographic variations between users and nonusers of sleep medications, this cannot be interpreted as absence of an effect because of uneven distribution and the underrepresentation of some demographic groups.

“[P]rescription sleep medication users endorsed stronger beliefs about the necessity of these medications and less concern about the consequences of use than non-users,” the researchers emphasized. “Thus, in order to minimize use of prescription hypnotics among patients with insomnia disorder, informing them about the risks of long-term use and effective non-pharmacological treatment alternatives will be important,” they concluded.


Tully IA, Kim JP, Simpson N, et al. Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder. J Clin Sleep Med. Published online March 8, 2023. doi:10.5664/jcsm.10552