D.F. Kripke on the Use of Sedative-Hypnotics: A Query

Here’s a question for any PoT readers who are physicians or who otherwise have experience prescribing sedative-hypnotics (aka, “sleeping pills”):

I’ve been working through D.F. Kripke’s paper “Mortality Risk of Hypnotics: Strengths and Limits of Evidence,” which claims that “hypnotics cause huge risks of” premature death in those who use them. In many ways, the paper strikes me as a methodological disaster area (here’s a cogent critique), but I’m curious what any physicians/prescribers out there think about two of the anecdotal claims Kripke makes about physicians who prescribe sedative-hypnotics.

Here’s the first one:

(1) There may be no authoritative documentation, but young hospital physicians are sometimes instructed to prescribe hypnotics so that they will not be awakened at night for such as-needed prescriptions. In such cases, the hypnotic prescriptions are to allow the physicians to sleep, not the patients. Allow me to document that this was my training at prestigious hospitals.

And here’s the second:

(2) There may be no published documentation, but physicians have repeatedly told me that they prescribe hypnotics in fear that unsatisfied patients will depart for new physicians. Physicians are fond of their patients, but it is difficult to exclude any financial motivation to retain patients. Unstated is the tendency for patients prescribed addicting drugs to return for refills to avoid withdrawal symptoms.

I’m curious whether Kripke’s claims ring true to physicians in practice, or whether he’s just over-generalizing and cherry-picking from his own experiences. Hard for a non-clinician to tell.

9 thoughts on “D.F. Kripke on the Use of Sedative-Hypnotics: A Query

  1. He is cherry-picking, but at the same time it is true that in some places at some times the rationale he describes for hospital-based prescribing of sedatives has been espoused by some doctors and in some cases propagated as a cultural norm among some of the medical staff. In those isolated cases, I cannot emphasize enough that it’s not primarily the doctors who are inconvenienced by the patient, it’s the person who has to stay on the unit and answer the call bell – the nurse.

    The pressure placed on doctors is generally mediated by night shift nurses – a hospitalized patient generally has no direct access to the on-call night shift doctor. The practices of individual nurses vary widely on this issue – some understand the harms of sedatives, particularly on hospitalized elders, and will do yeoman’s work trying to employ other means to get a patient through the night, others will call the doctor and describe what’s going on but defer to the doctor’s judgment about whether to order a sedative, and some will pressure the doctor relentlessly to order a sedative. It is almost exclusively in this last situation that doctors are faced with the choice to either give the nurse what she wants, or else risk what we call getting “hammer-paged” – interrupted so frequently and for so much time with the same repeated request that it jeopardizes your ability to handle your other work.

    It is important to realize here that the decision-making calculus for the doctor shifts from solely being concerned about a patient to one in which iterated relations with a professional colleague are involved, as are considerations about a scarce resource (my time). A night nurse has very intense hands-on responsibility for typically 6-8 patients; the covering hospitalist is usually primarily charged with doing a full history and physical and admission orders on 8-12 patients a night (this typically takes 45 minutes average per case), plus having ad hoc on-call responsibility for what may be 80-150 or more in-house patients. The “please order a sleeping pill” call comes in the context of one of these ad hoc calls while you’re trying to do something else under intense time pressure.

    More often the ad hoc calls you get relate to more serious deteriorations in patient condition (can’t breathe, critical vital signs, dying, dead). Because this is the reality of their work conditions, hospitalists who make their living in clinical practice, particularly on night shifts, are understandably dismissive of critiques of their practice patterns – especially those of the armchair variety that are often made by managers and oversight committees which are usually made up of people who rarely or never touch patients at all and are never near an acutely ill patient at 3:00am.

    Still, indiscriminate prescribing is not the rule, and is not generally used as a crutch to “help the doctor sleep.” I actually don’t know any hospitalist in practice who works the night shift at a hospital bigger than 60 beds who sleeps for any significant amount of time during a shift. The ones at the smaller hospitals might sleep, but are often on duty for 168 hours in a row of a working week. Sleeping on call, and hatching schemes to game the system so you sleep through your call night, is a quaint circa 1970s-80s concept depicted in works like the novel “House of God,” etc.

    As for the assertion that doctors are afraid that patients will get angry and leave them if they don’t prescribe the drugs they’re seeking, it’s absolutely true in my experience that patients often (like, every day I work) pressure doctors to prescribe these medications in the hospital, and get angry when we decline. But in almost every place nowadays, hospitalists (or residents) are literally the only game in town while you’re hospitalized. The patient can’t “leave” me except to elope from the hospital against medical advice while acutely ill. And I would estimate that outside the circumstance of patients on ventilators, in florid alcohol withdrawal, or on terminal care, the incidence of my prescribing a de novo sedative drug to a patient from among the sedative orders I give is far less than 10% of my total sedative orders – hospitalists typically order sedatives for the 3-5 days of a hospital stay because someone else is already doing so the other 360-362 days of the year, and because most of these drugs have withdrawal effects.

    So my “line in the sand” as a hospitalist in saying no is generally useless, worthless, and counterproductive. Are the outpatient prescribers affected by the motive that they’ll lose a patient if they don’t prescribe? I don’t have the experience to answer, but my sense when I talk to PCP’s about their patients is, it’s far more complicated than that, and making the doctor the sole locus of culpability for these situations (which has become standard operating procedure in healthcare generally) may feel good for everyone else, but doesn’t accurately capture these decisions and the way they’re actually made most of the time. In every community there are doctors who go crazy with polypharmacy, and will give a drug for every symptom or unpleasant experience. Patients who want that kind of care often self-select into their practices. In my experience it’s more prevalent the more white, affluent, and demanding from a “customer service” angle the clientele is. I don’t think you can make appraisals about the practice patterns without very dependable, unbiased, hard data.

    Finally, I find it rich that medical journals are now at the same time publishing studies documenting the negative health effects of sleep loss on hospitalized patients. The environment of a hospital couldn’t be less conducive to sleep, and I can’t change the physical plant, institutional climate control, noise level, etc. for a patient. So now you’re saying lack of sleep is dangerous for the patient, and what exactly am I supposed to with that information?

    This is a classic conundrum in medicine: two separate parties publish research on two different isolated aspects of a complex issue, asserting “trends toward unfavorable outcomes” related to condition “A,” and related to condition “B,” which represents the only viable alternative to condition “A.” And invariably lay readers and academics not heavily engaged in direct patient care offer critiques that get the doctors both coming and going, asserting with no evidentiary support that there must be some condition C that represents a golden mean or a “working smarter,” virtually always making a backhanded assertion that “better communication” is some magic potion that will cure everything, again without evidence to support the implication that the unfavorable outcomes were necessarily accompanied by poor clinician communication.

    For years we were told, and are still told, that “pain is the 5th vital sign” and you are a monster for withholding pain meds, but then also: your pain killer prescriptions are killing people in epidemic proportions! Notably, never once has the latter revelation led anyone involved in the dialogue to make a clear statement to the effect that: “Hey, that 5th vital sign stuff? That was totally overzealous! You really shouldn’t think of it that way anymore!” This paradigm – catching clinicians between two critiques that are really just a rhetorical cul-de-sac – actually captures a very large percentage of what administrators get paid to pontificate about, what healthcare consultants get paid to sanctimoniously lecture clients about, and what is driving nurses and doctors out of clinical practice. It’s very expressly designed in my opinion to foster blind obedience on the part of clinicians to whatever the initiative-du-jour is by reinforcing a constant sense of inadequacy. So in a way everyone is cherry-picking, not the least of which are the academic researchers, whose motive in doing the research too often isn’t to help clinicians solve problems, but rather to publish, get more grants, get full professor, etc. – or who at the very least fail to speak out against specious applications of their research.

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      • I think hospitalists are more at fault at the macro-, systemic level, where they’ve abdicated [responsibility], and adopted a stance of total conformity to whatever their parent institutions want them to do or believe, partly because of a deep-seated inferiority complex about the discipline of hospital medicine itself, and partly out of a desperate need to “demonstrate their value.” As a consequence, they’ve forfeited for the entire subspecialty the prerogative of independent critical thinking in the clinical domain.

        My problem relating to academic researchers is more with the selective appropriation of academic research by non-academics to push policies and initiatives through, particularly in the “Quality” and “Patient Safety” domains. It’s a ubiquitous practice for government agencies, hospital administrations, and practice leaderships to use the mere fact of a published study about something to pre-empt dissent and dialogue about policies they impose on clinicians. It’s particularly rampant to use science – often bad science – as a bludgeon in the community, where we don’t research or publish, and therefore it’s presumed that we lack the qualifications to question something that someone said appeared in a paper. Very often the so-called “evidence-based” mandates imposed on us are supported by studies that had nothing to do, methodologically or contextually, with the application. Like the meaningless 2.5mg of ramipril habitually given thousands of times over on discharge to 95-year olds who had fluid overload of any kind during a hospital stay, because it’s hell on earth to convince people – let alone an EMR that won’t let you advance to the next screen – that this practice has no business being called a “core measure” for anything.

        My problem with academic researchers in this context is that I think they know better and I never see them say it when specious interpretations of their research proliferate. I can’t come up with a better conclusion than that there’s a conflict of interest when a bunk application of someone’s study makes that someone a star in the field.

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        • Suleman,

          I can’t speak to the parts of your comment that are specifically about hospitalists, but I very much agree with the rest–it’s actually a really important point, and it goes well beyond medicine. Selective appropriation of academic research to push policies through has become a widespread problem that borders on being a scam. In education, you regularly see people touting some asshole policy as exemplifying “best practices” on the basis of a long bibliography of obscure references (cf. “Bloom’s Taxonomy”). Unless you have the time to wade through all that crap, you seem to have no choice but to say, “Well, I guess the literature is on your side!” But if you do wade through it, you’d be amazed to see what BS is being cited, and how cynically it’s being misrepresented even if it’s not BS. Half the time “research” functions as a means of intimidation, not communication.

          That’s the grain of truth in the anti-expertise aspect of the Trump phenomenon. People have gotten far too used to making fallacious appeals to pseudo-expertise, and waving an impressive-looking bibliography around to end discussion. The Kripke article in my original post is a perfect example. This article based on it sounds really scary, but could easily have been titled, “More Highly Problematic Evidence that Sedatives May Raise Risk of Premature Death–Consistent with the Possibility that there’s No Real Risk there At All if You Take the Right Dose the Right Way for the Right Indication.”

          http://www.medscape.com/viewarticle/728461

          Also on point and well worth reading:

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/

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    • Suleman–

      On re-reading your comment, it occurs to me that either Kripke’s clinical experiences have been extremely idiosyncratic, or yours have been–or else, as far as clinical work is concerned, Kripke literally doesn’t know what he’s talking about. Either way, it seems problematic that a journal editor allowed him to sound off in the way that he did. The discrepancy between your account and his raises interesting questions about the gap between academic medicine and (for lack of a better term) clinical medicine, and generally between academia and the world of practical affairs.

      It also raises questions about the editorial practices of the journal in which the article appeared. On closer inspection, it’s not clear to me whether the journal, Drug Safety, is a peer reviewed publication, or even makes any pretense to impartiality or balance. Despite having the outward trappings of scholarship (and being published by a reputable publisher), it actually looks a bit like the house journal of a partisan organization, the International Society of Pharmacovigilance. I don’t know the details, but I’m more than a bit skeptical.

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  2. Thanks for these comments, they’re very helpful. I actually think Kripke’s use of these anecdotes is worse than either of you realize, because you don’t know the original context of the quotations. The truth is that it’s a very badly done study–so bad that I have trouble understanding why it was published in the first place (despite the prominence of the author). He’s offering up the anecdotes to compensate for the fact that the supposed “mortality” that he claims to have shown as a result of sedative-hypnotic use is purely associational, and none of the studies claim to have controlled for all relevant confounding variables (so that no bona fide causal inferences are possible). To gloss over this fact, he offers the anecdotes in order to insinuate that the mortality rate is probably higher than the studies show; it’s just that a lot of prescribing is unscrupulous and off-the-books, hence is not documented in studies. We’re supposed to conclude that he has phantom evidence that the use/mortality hazard index is so high, and the confidence intervals are so good, that we must be in the presence of a clear-cut causal relationship: use equals death.

    The fallacy here is known as ignoratio elenchi: failure to grasp the burden of proof. I’m sure it’s true that a lot of prescribing is off the books and done under pressure (etc.) but that doesn’t prove his thesis, which is that prescribing of sedative-hypnotics is so unsafe that it should just stop (except for hospice care for the terminally ill). There are too many problems with the study to belabor right now, but I think your comments convince me that the anecdotes are really just a desperate attempt to bolster a bad argument.

    As a general point, I’ve become a lot more sensitive over the years to the gap between academic commentary and real-live practice, whether political, clinical, or otherwise. Academics tend to denigrate “mere experience” as though it counted for nothing, a problem that doesn’t seem limited to pure theorists. It seems to afflict academic practitioners as well, in medicine and elsewhere.

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    • Yeah, no kidding. I didn’t want to read beyond the abstract because I’m rather suspicious of this type of “study.”

      If I get the sense that research is motivated by moralistic assumptions, I’m already bored. Try dealing with these people when you’re actually working in the field.

      I don’t know how many of you have seen a person who hasn’t slept in months, but it’s not pretty. I tend to empathize with the patient rather than the know-it-all researcher/academic whose Christian moralizing interferes with his/her ability to empathize and actually treat a very real problem. Who cares if some people overdose on these drugs or studies show that the mortality rate is higher? We don’t know why the mortality rate is higher; it could be any number of things some of which are relevant and some of which are not.

      The important thing is the patient in front of you who hasn’t slept in six months, and can’t work and isn’t relating well to family and friends and is ready to jump off a bridge. In my experience, the act of jumping off bridges results in a 100% mortality rate (and that’s really high).

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  3. My off-the-cuff-while-on-vacation response on the two questions in the original post:

    1. This is the case for two or three types of medical providers: undermotivated and/or poorly-incentivized phyicians, including hospitalists and resident physicians, as well as hospitalized nurses.

    2. Not very true. We all have plenty of patients, and it’s not that difficult to discuss alternatives with them. Again, those MDs who are too busy to take time may be culprits, but this is a minority.

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  4. I had a brief conversation on this topic yesterday with the other Dr. Khawaja (my father, a retired surgeon), whose view was closer to Kripke’s than it was to either Suleman Khawaja’s or William Dale’s.

    On (1), his view was that residents have an tendency to write prescriptions for sedatives simply because a patient has made a request for one, not so much to be able to sleep themselves, but because they can’t think of a reason for denying the request. (Kripke’s arguments to one side, it’s not clear that there is a good reason for denying such requests. Patients need sleep, and it’s not easy to sleep in a hospital. It’s not clear why suspicion or conservatism should be a first resort in this context.)

    On (2), he tended to agree with Kripke that private practice physicians do over-prescribe sedatives, without explicitly saying that they did so to keep patients. I got the sense that the issue was more a matter of keeping patients happy than of keeping them per se.

    So we’re now up to a sample size of 3 (physicians).

    Obviously, even if everything my father said is right, the correctness of his claims can’t make up for the methodological defects of Kripke’s study.

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