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Awakening to better sleep therapies

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Taking into account the link between chronic pain and insomnia, the workers compensation industry is educating health care providers and injured workers about sleeping pill alternatives to improve patient safety.

Sleeping pills, known as sedatives or hypnotics, made up just 2.6% of workers comp prescriptions in 2014, according to pharmacy benefit manager Helios' most recent drug trend report. However, drugs such as antidepressants, which accounted for 7.3% of prescriptions, and muscle relaxants, which accounted for 10.4%, often are used off-label to treat insomnia, which experts say makes it difficult to get a clear picture of utilization.

“Poor quality and insufficient duration of sleep are among the strongest predictors for pain in adults over 50,” Dr. Terrence J. Wilson, Dallas-based utilization review medical director at managed care services provider Genex Services L.L.C., said in an email.

The relationship between pain and insomnia is why sleep aids often are prescribed with other categories of medications, such as opioids, he said.

According to a 2015 poll by the Arlington, Virginia-based National Sleep Foundation, two-thirds of people with chronic pain also experience trouble sleeping.

There's a “vicious cycle” between chronic pain, insomnia and depression, said Dr. Robert Hall, Westerville, Ohio-based corporate medical director at Helios. Physicians usually try to get an injured worker's pain under control before addressing insomnia in hopes of breaking the cycle, he said.

Introducing sleeping pills can be dangerous, since many medications injured workers take for chronic pain — including muscle relaxants, benzodiazepines and opioids — “have this additive effect of suppressing the central nervous system,” which can be fatal, Dr. Hall said.

Sleeping pills such as Ambien and Lunesta, the two most popular hypnotics used in workers comp, usually are prescribed near the six-month mark, when an injured worker's pain is controlled during the day but he or she still has trouble sleeping at night, experts say.

“They are typically prescribed because of side effects from opioids that create sleep disorders,” Mark Pew, senior vice president at Duluth, Georgia-based medical management company PRIUM, said in an email. “Alternative options obviously are to reduce dosage or remove drugs that create insomnia side effects.”

Identifying potential causes of insomnia can help prescribers avoid sleeping pills altogether, Dr. Hall said, as medications for group health conditions such as high blood pressure also can disrupt sleep.

Stimulants such as Provigil and Nuvigil, which sometimes are prescribed to help injured workers taking several medications stay awake during the day, also can lead to insomnia, said Susan Martin, Westerville-based senior clinical pharmacist at Helios.

“Rather than just taking the stimulant away and reducing some of the doses on the other medications,” injured workers might be prescribed a hypnotic to help them sleep, Ms. Martin said.

However, workers comp professionals are wising up to the potential dangers of sleeping pills and pushing health care providers to explore other therapies before prescribing sedatives or hypnotics, experts say.

“Providers are increasingly looking at alternatives, such as cognitive behavioral therapy and progressive muscle relaxation training,” Dr. Wilson said. Physicians should “consider using sleep hygiene questionnaires and reinforcing the basics,” such as regular exercise, going to bed and waking up at the same time each day and limiting caffeine and alcohol, he said.

Other sleep hygiene techniques include keeping the bedroom cool and dark, not exercising or watching TV right before bed, and avoiding naps and nicotine, experts say. An over-the-counter medication such as melatonin also is safer than prescription sleeping pills, they add.

Though it depends on the employer, sleeping pills typically require prior authorization, said David Lupinsky, Folsom, California-based vice president of medical review services at third-party administrator and managed care services provider CorVel Corp. It then could go to utilization review, but the goal is “not just to have a roadblock,” he said.

“If we see a request like this, our hope would be to circle back and either do some coaching with the attending (physician) on trying sleep hygiene techniques first, or just going directly to the injured worker … and educat(ing) them on good sleep hygiene,” Mr. Lupinsky said.

Either way, good sleep hygiene techniques should be used in conjunction with medications, which might not work as well over time, Mr. Lupinsky said.

“The use of medications for sleep is not a good long-term solution,” said Dr. Steven Feinberg, chief medical officer at Feinberg Medical Group in Palo Alto, California, and an adjunct clinical professor in the anesthesia/pain management department at the Stanford University School of Medicine. “That doesn't mean they shouldn't be used at all; but in workers comp, at least in my state, we see people who are on long-term sleep aids who have never been counseled or gotten any benefit of learning proper sleep hygiene.”

In the past three years, payers have been more willing to pay for sleep aids such as cognitive behavioral therapy, yoga, gym memberships and sleep studies, Mr. Pew said.

“It has taken positive affirmation of their benefits to change industry perceptions and reimbursement behavior,” Mr. Pew said.

One of the most proactive things workers comp professionals can do is educate health care providers and patients about a more conservative approach, sources said.

“If I say, 'You really should consider having this patient enroll in cognitive behavioral therapy and undergo sleep hygiene,' (the provider) may not know what the next step in their community is for that,” Dr. Hall said. “How do you go about finding that local expert who can help with those types of services? That's the challenge.”