Quetiapine or Cannabis for insomnia?
Insomnia is a condition that has plagued mankind for millennia. Many remedies have been sought, with no perfect cures yet found. Current practice advises exercise, rigorous sleep hygiene and cognitive behavioral therapy over medications, yet medications are often prescribed for recalcitrant cases.
Benzodiazepines have been used in the past, but addiction issues and long term effectiveness limit their use. The Z-drugs tend to be first choice, but ineffective for many people. Diphenhydramine, found in Benadryl and many OTC sleep remedies has been linked to dementia with chronic use. Many physicians move on to off-label (and poorly studied) treatment of insomnia with sedating psychiatric medications, such as trazodone, quetiapine and risperidone.
A. Cannabis for insomnia
In September 2014, the College of Family Physicians of Canada released their guidelines for authorizing dried cannabis for chronic pain or anxiety. This was based on the nonsystematic review performed by Kahan, et al. Their conclusion:
Recommendation 3
Dried cannabis is not an appropriate therapy for anxiety or insomnia (Level II).
B. What is the evidence for using cannabis for insomnia?
There have been very few studies directly looking at the effect of cannabis on sleep. Most studies looking at cannabinoids in sleep have been done using synthetic cannabinoids and sleep has usually only been recorded as one of many outcomes. A review of these studies found that most were of poor quality, with failure of blinding and other risks of bias. It is unclear what effect cannabis has on the sleep of healthy cannabis users, but in medical users most studies show an improvement in the quality of sleep without affecting total sleep time.
It is understood that Canadian family physicians do not want to prescribe a medication for insomnia that is prone to abuse, has little evidence to support its use in insomnia and/or anxiety and has significant side effects. So how then do we explain the inherent hypocrisy of the widespread prescribing of quetiapine (Seroquel), a drug that fulfills all these criteria, for this indication?
C. What are the problems with prescribing quetiapine for insomnia?
Many physicians are unaware of the abuse potential of quetiapine, endemic in the penal system. Low-dose quetiapine tablets are known on the street as “baby heroin” or “Susie-Q” and are sold for $5–8/pill. The FDA has noted that quetiapine has been associated with sudden cardiac death, movement disorders and a significant risk of metabolic syndrome. The use of quetiapine for insomnia was associated with an average weight gain of 2.2 kg over 11 months, as well as exacerbating hypertension and dyslipidemia.
David Juurlink puts it bluntly:
“That’s just bad medicine,” said Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto. “These are drugs that used even in the right indications, have side effects that can be lethal. [Quetiapine] is an anti-psychotic drug, and when it’s used indiscriminately it can kill people.”
Despite this, quetiapine is the 9th most prescribed medication in British Columbia, with 58% of the prescriptions for the low dose tablet (25 mg) indicating use predominantly for sleep disturbances. The motivation for such an unparalleled acceptance of this bizarre and dangerous practice remains unclear, although pharmaceutical influence cannot be discounted.
D. What is the role of industry influence in quetiapine prescribing
The College of Family Practice of Canada (CFPC) has been under pressure recently to be more transparent about the contribution of industry funding in their continuing education programs
The agency that certifies Canada’s family doctors says it will keep taking drug-industry money to pay for its education programs despite commissioning a report on Big Pharma’s influence, which it then kept under wraps for two years….
“This is a funding vacuum that the pharmaceutical industry has filled for most family physicians’ practice lifetimes,” college leaders write on the website, healthydebate.ca. “In the absence of public funding, the private sector filled the void. This is not a (college) decision but a reality with which we live.”
In Canada, AstraZeneca and the College of Family Practice of Canada have partnered for the At My Best program, to fight childhood obesity, an admirable goal, especially for the toddlers who have been prescribed quetiapine or other atypical antipsychotics.
The government’s investigation was brought about as a result of a whistleblower lawsuit. The resulting allegations stated that between 2001 and 2006 AstraZeneca promoted Seroquel to psychiatrists and other physicians for disorders not covered by FDA approval. These off-label indications spanned a broad range of conditions including aggression, Alzheimer disease, anger management, anxiety, ADHD, bipolar maintenance, dementia, depression, mood disorder, post-traumatic stress disorder, and sleeplessness. Moreover, it is claimed, AstraZeneca promoted Seroquel to physicians who don’t normally treat patients with schizophrenia and bipolar disorder, the two approved disorders for the drug.
The firm was also accused of “improperly and unduly” influencing company-sponsored continuing medical education programs and violating the federal Anti-kickback Statute. This violation included the payment of doctors to advise AstraZeneca about marketing messages for unapproved uses of Seroquel, give promotional lectures to other healthcare professionals, or serve as authors of articles written by AstraZeneca and its agents about the unapproved uses of Seroquel. As a result of such false marketing, AstraZeneca was alleged to have effectively caused false claims for payment to be submitted to federal insurance programs including Medicaid, Medicare, and Tricare as well as to the Department of Veterans Affairs, the Federal Employee Health Benefits Program, and the Bureau of Prisons.
Best practice discourages the use of medications for insomnia in favor of cognitive behavioral therapy and rigorous sleep hygiene, but in the “reality with which we live”, medications form a significant portion of the treatment plan. Prescribing those medications should be based on a mixture of evidence and harm/benefit ratio.
Neither quetiapine or cannabis are proven treatments for insomnia; however, if you are planning to prescribe (or consume) a medication for insomnia that has abuse potential and little evidence to support its use, why not the one with centuries of use without overdose, reduced incidence of obesity and metabolic syndrome (cannabis) rather than the one that has been overly promoted by industry, associated with weight gain, akisthisia and sudden cardiac death (quetiapine)? In the end, stigma is leading many physicians to pick the more dangerous choice.