Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration (VHA)

Abstract

Use of nonbenzodiazepine sedative hypnotics, especially zolpidem, has grown substantially, raising concerns about safety. Gender‐specific guidelines have been recommended for appropriate zolpidem prescribing to address patient safety concerns. In line with an FDA recommendation in 2013, the Veterans Health Administration (VHA) issued a similar directive to lower the doses of zolpidem in women in 2013. However, little is known about zolpidem prescribing patterns in the VHA in general. Therefore, the goal of this study was to examine utilization trends and inappropriate prescribing of zolpidem in accordance with VHA guidelines in male and female veterans in the VHA.A cross‐sectional study of veterans receiving zolpidem in the outpatient setting from October 1, 2011, to September 30, 2016. We examined 2 outcomes related to inappropriate zolpidem prescribing: high‐dose and overlap with benzodiazepines.The study population consisted of 500 332 zolpidem users (58 598 women and 441 734 men) and a random 10% sample (n = 631 449) of nonusers.Across the VHA, 7.1% of men and 10.0% of women received zolpidem at least once during the study period. In 2016, 29.7% of female veterans received an inappropriately high guideline‐discordant dosage compared with 0.1% of male veterans (P < .001 for all reported comparisons). Furthermore, more women than men had overlapping benzodiazepine and zolpidem prescriptions (18.8% vs 14.3%). In unadjusted trends in high‐dose zolpidem prescriptions by gender before and after the VHA 2013 recommendations for suggested lower dose in women, we found that the observed proportion of women receiving the higher dose decreased considerably from 75.9% in 2011 to 29.1% in 2016. For men also, there was a decline in observed receipt of high‐dose zolpidem from 1.7% in 2011 to 0.1% in 2016. In fully adjusted models, inappropriately high doses were more commonly received by younger women (adjusted odds ratios [AORs]: 2.75 for 21‐39 years and 2.97 for 40‐49 years compared with ≥ 80 years) and women with substance use disorder (AOR, 1.48). In the second inappropriateness outcome models, women with anxiety (AOR, 2.28) or schizophrenia (AOR, 2.05) and men with cancer (AOR, 1.42), anxiety (AOR, 2.66), or schizophrenia (AOR, 2.46) were more likely to receive an overlapping prescription of zolpidem and benzodiazepines.We found inappropriate prescribing of zolpidem, in terms of both guideline‐discordant dosage and coprescribing with benzodiazepines, with female Veterans affected more than male Veterans. Potential contributors to this inappropriate prescribing of zolpidem in women could include the fact that the majority of patients served by the VHA are men. Hence, providers may be less familiar with issues specific to treating female veterans.Findings have implications both for patient safety and promoting guideline‐concordant prescribing in female zolpidem users, specifically those with existing mental conditions. These findings may help guide and inform intervention efforts targeted toward these female Veterans to optimize zolpidem prescribing in the VHA. Greater understanding of the drivers of this inappropriate prescribing is necessary to develop interventions to promote safer, more guideline‐concordant prescribing.Department of Veterans Affairs.