Incidence and Predictors of Long-term Hypnotic Receipt among Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Many patients with chronic obstructive pulmonary disease (COPD) receive hypnotic prescriptions to mitigate insomnia symptoms. Although clinical practice guidelines advise short-term use, patients often receive these medications long-term. As patients with COPD may be more susceptible to adverse effects of hypnotics, it is critical that we better understand the incidence and potential influences of this practice.

Objectives: To characterize the incidence and predictors of guideline-discordant long-term receipt of hypnotic medications among patients with COPD.

Methods: Using nationwide Veterans Health Administration (VA) data, we identified patients with clinically diagnosed COPD from 2010-2019 without prior hypnotic receipt in the past year. To identify individuals with new hypnotic use, we restricted this sample to those who received at least 30 total days of zolpidem, melatonin, trazodone, and/or doxepin within a 90-day period. We defined long-term hypnotic receipt as continued availability of one of these hypnotic medications for at least 30 days within the subsequent 90-day period. We then used a mixed-effects logistic regression model to assess patient and site-level associations with long-term receipt.

Results: Among 4,262 patients with COPD and new hypnotic receipt, 55.6% (2,371) continued to receive hypnotics long-term. Long-term receipt was positively associated with short-acting beta agonist (SABA) receipt (Every 10% increase in days with SABA availability, OR 1.03, 95%CI 1.02-1.05), maintenance inhaler prescriptions (monotherapy, OR 1.35, 95%CI 1.10-1.68, dual therapy, OR 1.43, 95%CI 1.20-1.70, triple therapy, OR 1.54, 95%CI 1.24-1.91), post-traumatic stress disorder (OR 1.21, 95%CI 1.02-1.44), major depressive disorder (OR 1.24, 95%CI 1.07-1.44), anxiety disorder (OR 1.21, 95%CI 1.03-1.44), and more frequent primary care visits (>5 visits in the past 12 months: OR 1.86, 95%CI 1.19-2.90). Long-term receipt was negatively associated with initial receipt of melatonin (OR 0.70, 95%CI 0.55-0.91) and more than one pulmonary visit in the prior 12 months (OR 0.74, 95% CI 0.56-0.97).

Conclusions: Despite guideline recommendations, long-term hypnotic receipt is common among patients with COPD. Future work to prevent long-term hypnotic prescriptions should consider the role that respiratory symptoms and mental health comorbidities may have in driving this practice.