Enhancing Hypnotic Medication Discontinuation in Primary Care through Supervised Medication Tapering and Digital Cognitive Behavioral Insomnia Therapy

项目总结/摘要 寻求治疗的失眠患者最常出现在初级保健中，他们的第一次也是通常唯一的一次 治疗是一种处方催眠药。超过65%的个人处方催眠药使用它们， 超过一年，超过30%的人留在他们身上超过五年。这样的试剂可用于 急性失眠和某些慢性睡眠困难的病例，但长期使用催眠药可导致 依赖性和增加的发病率（例如，福尔斯、认知/驾驶障碍）。减少或停止 长期使用催眠药对处方医生和使用催眠药的患者来说都是一项具有挑战性的任务。 他们尽管循证医学医生监督的药物减量（SMT）协议显示， 尽管这些干预措施有效，但尚未在初级保健中广泛传播。大多数初级保健提供者 （PCP）愿意将他们的失眠患者转介给替代性循证非药物治疗，如 认知行为失眠治疗（CBTI），但这种治疗往往很难获得专业以外的 睡眠中心鉴于研究和临床实践之间的这种差距，迫切需要开发和 验证具有成本效益的干预措施，以促进对失眠和催眠逐渐减少的管理， 在乎作为对PAR-20-183的回应，此应用程序经过精心设计，可解决这些问题。我们 将进行一项大型随机试验，比较数字CBT（dCBTI）/SMT联合干预与 SMT干预单独给药，用于产生催眠停药和失眠症状改善。 在一项基于实践的研究中，从8-10个初级保健诊所抽取了430名高血压依赖患者的样本 一个附属于科罗拉多奥罗拉市的科罗拉多大学医学院的网络将作为研究对象 参与者本项目的主要目的是比较dCBTI+SMT与所用SMT的性能 单独用于实现催眠减少/中止和失眠症状改善。另外我们 将在随机对照试验中纳入强制性实施评估，以确定患者-提供者-以及 可能影响采用、实施和维持各类干预措施的系统层面因素 测试.成效/实施方面的调查结果应有助于设计今后的实施试验 本文确定的促进dCBTI和SMT干预措施在初级保健中传播的策略应 这些治疗在目前的试验中证明是有效的。我们还将收集探索性数据， 对dCBTI/SMT的反应最好。这项研究将提供新的和有用的信息， 效用，以及患者，提供者和系统层面的可接受性，这些干预措施，以管理失眠， 减少/消除初级保健中催眠药的使用。该项目应作为实现以下目标的必要的第一步： 最终传播可获得的、具有成本效益的战略，以管理重大的公共卫生问题， 改善数百万长期使用受控物质助眠剂的人的生活质量。

PROJECT SUMMARY/ABSTRACT Treatment-seeking insomnia sufferers most often present in primary care where their first and usually only treatment is a prescription hypnotic medication. More than 65% of individuals prescribed hypnotics use them for more than a year, and more than 30% remain on them for more than five years. Such agents may be useful for acute insomnia and certain cases with chronic sleep difficulties, but prolonged hypnotic use can lead to dependency and increased morbidity (e.g., falls, cognitive/driving impairments). Reducing or discontinuing hypnotics after prolonged use is a challenging task for both prescribing physicians and the patients who use them. Although evidenced-based physician-supervised medication tapering (SMT) protocols have shown efficacy, such interventions have yet to be disseminated widely in primary care. Most primary care providers (PCPs) are willing to refer their insomnia patients to alternative evidence-based non-drug treatments such as cognitive behavioral insomnia therapy (CBTI), but such treatment is often difficult to access outside of specialty sleep centers. Given this gap between research and clinical practice, there is a pressing need to develop and validate cost-effective interventions to facilitate the management of insomnia and hypnotic tapering in primary care. In response to PAR-20-183, This application has been carefully designed to address these issues. We will conduct a large randomized trial to compare the combined digital CBT (dCBTI)/SMT intervention, to the SMT intervention delivered alone for producing hypnotic discontinuation and insomnia symptom improvement. A sample of 430 hypnotic-reliant patients drawn from 8-10 primary care clinics within a practice-based research network affiliated with the University of Colorado Medical School in Aurora, Colorado will serve as study participants. The main objective of the project is to compare the performance of dCBTI+SMT with SMT used alone for achieving hypnotic reduction/discontinuation and insomnia symptom improvement. In addition, we will incorporate an Effectiveness-Implementation assessment into the RCT to identify patient- provider- and system-level factors that may impact adoption, implementation and maintenance of the types of interventions tested. Findings from the effectiveness/implementation should help design future trials of implementation strategies identified herein to promote dissemination of dCBTI and SMT interventions into primary care should these treatments prove effective in the current trial. We also will gather exploratory data to determine who responds best to dCBTI/SMT. This study will provide new and useful information about the feasibility, clinical utility, and patient-, provider-, and system-level acceptability of these interventions to manage insomnia and reduce/eliminate hypnotic use in primary care. This project should serve as a necessary first step toward the eventual dissemination of accessible, cost-effective strategies to manage a significant public health problem and improve the quality of life of millions of chronic users of controlled-substance sleep aids.