Insomnia and Sleep Disorders in Primary Care Settings - Episode 9

Access and Treatment of Insomnia in Primary Care Clinics

An expert in sleep medicine highlights challenges in prescribing DORAs and importance of discussing insomnia with patients in the primary care setting.

Paul Doghramji, MD, FAAFP: There are some challenges when we prescribe these newer agents, the DORAs because all 3 of them are branded products and they're relatively expensive. They don't have a generic counterpart compared to the older ones, the Z-drugs, which all come out in generic and are relatively expensive. And as a result, insurance companies will also have a say in it where they will want patients to try a generic, inexpensive medication like a Z-drug first before they will pay for one of the newer branded DORA products. The way to get around that sometimes if you want to prescribe a DORA and you think that's the right one and benzodiazepine or a benzodiazepine receptor agonist is not the right one is you can give samples out to patients. There are coupons, there are vouchers which you can use. Now, the newest one, the newest medication, which is daridorexant, they have a specific way where you can write the prescription out to a specific remote pharmacy where that remote pharmacy can contact the patient and have 30 days of the medication sent to the patient free of charge if they have commercial insurance. The patient can then try out that medication free of charge no matter what if they have commercial insurance and have a good trial of 30 days of that medication. Followed by after that, the medication can then either go through insurance or if it still doesn't, they can pay $25 a month for continuation of that medication. One company at least has tried to get the medication into a patient's hands in an easier way. And this is one of the things that makes daridorexant attractive to prescribe for our patients. Because again, if you can't get the medication into your patient's hands, of what use is it?

The one month that the daridorexant company is supplying a patient who has insomnia for free if they have commercial insurance is good. Now, obviously, I'd like to see it a little bit longer for me to be able to judge how well a patient is doing, maybe 6 or 7 weeks or so. But again, if they're doing well after one month, I'll want to then encourage the patient to go onto the second month so I can see by halfway through that second month where they are. Because that's probably going to be their peak benefit time. It is important for them to get the medication for a longer period than one month, but at least the one month is a very good start.

Insomnia is a risk factor for many psychiatric and medical conditions. People have a poorer quality of life and more negative outcomes because of poor sleep from insomnia. We in primary care, are best suited in identifying these patients and doing something about it. We need to be proactive. We see our patients very regularly over time. We are primary care providers. We're not emergency room physicians or emergency room providers where they come and go. These patients are coming to us all the time. We have many opportunities to ask about a patient's sleep. And if they're not doing very well, we need to be proficient at knowing which questions to ask to be able to get to the root of what's going on with their insomnia. We also need to know what the treatment options are, including cognitive behavioral therapy, including sleep hygiene, which is part of cognitive behavioral therapy, including the medications that are out there. We need to be proficient and know how to prescribe these medicines. We also need to talk to our patients about expectations that we want to get their sleep to be as good as possible so they're sleeping well through the night and feeling well throughout the day. And those should be our goals. And if we can't achieve that, then we can certainly get some help from our sleep experts. That's the main message that we need to impart to our primary care clinics about insomnia and their patients.

Transcript Edited for Clarity