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Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997; 154:1,417-1,423.
About 10% of U.S. workers suffer from insomnia, and the problem has a significant negative effect on productivity and health care utilization, according to this study by researchers at the Group Health Cooperative of Puget Sound in Seattle.
The Group Health Cooperative is a health maintenance organization with about 390,000 members in Washington. The researchers studied 373 patients who were eligible and willing to go all the way through a series of assessments. They found a 10% prevalence rate for insomnia, defined as taking at least two hours to fall asleep nearly every night. That is a somewhat lower rate than that found in some other studies, but the diagnostic threshold was high enough to identify a group of patients who clearly had insomnia.
The study suggests insomnia affects functional impairment as much as many other psychiatric and general medical disorders. Patients with insomnia were found to have 3.5 days of disability more than others without insomnia. "The prevalence of moderate or severe occupational role disability in the patients with insomnia (24%) is similar to that reported for patients with noncomorbid generalized anxiety disorder or somatoform disorder," the authors write. Those with insomnia tended to have one more "bed day" per month than others, which the researchers say is comparable to the excess disability associated with lung disease or diabetes.
"Our findings do not suggest overprescription of benzodiazepines or other hypnotic drugs to primary care patients with insomnia," they say. "Approximately 15% of the patients with current insomnia received prescriptions for benzodiazepines, and fewer than 20% of those with insomnia not associated with depression were treated with antidepressants."
The study results suggest the potential for major improvements in productivity if insomnia is treated effectively, the authors say. But they also point out that benzodiazepines and sedating tricyclic antidepressants significantly increase the risk of accident and injury. The researchers also caution that clinicians must recognize insomnia as a separate problem of its own, not just a symptom of depression.
"Depression is a powerful predictor of disability and health care utilization, but insomnia appears to make an important independent contribution." t
Mitler MM, Miller JC, Lipsitz JJ, et al. The sleep of long-haul truck drivers. N Engl J Med 1997; 337:755-761.
Long-haul truck drivers routinely work without the proper rest, significantly increasing the risk of accidents.
These researchers conducted round-the-clock electrophysiologic and performance monitoring of four groups of 20 male truck drivers. Two of the groups were working in the United States with five 10-hour trips of day driving beginning about the same time each day, or night driving beginning about two hours earlier each day. The two groups in Canada drove four 13-hour trips of late night to morning trips beginning at about the same time each evening, or afternoon to night driving beginning one hour later each day.
The 80 male commercially licensed drivers were told the purpose of the study. They followed their normal routes and were free to stop and rest, nap, or withdraw from the study. The drivers had no financial incentive or disincentive to take naps.
They completed questionnaires, and they were monitored electronically while sleeping. Infrared video systems installed in their trucks recorded the drivers’ faces and the road ahead, and computers recorded the truck’s speed and road position while instruments measured the drivers’ brain activity. All of that data were synchronized to provide a picture of the driver’s face and the circumstances of the moment. The researchers analyzed the videotapes to assess whether the driver looked drowsy, based on drooping eyelids and a bobbing head.
The drivers slept for an average of 4.78 hours per day, about two hours less than their reported average ideal sleep per day. Thirty-five drivers took at least one nap per day, increasing their total sleep time by an average of 11%. When concentrating on the videotape showing the truck going at least 45 miles per hour, the researchers found two trips in which the drivers had a total of seven episodes with electrographic features of drowsiness such as slow, rolling eye movements and electroencephalographic alpha activity. "These episodes qualified as stage 1 sleep," the researchers say.
Of all the tapes analyzed, 7% showed a drowsy driver and 56% of the drivers were found to be drowsy in at least one segment. Eighty-three percent of the drowsy segments occurred between 7 p.m. and 7 a.m.
"Since physicians are a primary source of information about fitness for duty and its relation to sleep, they should be alert to the possibility of sleep deprivation in people who engage in shift work," they write. "It is also important to recognize the deleterious synergistic effects on alertness of alcohol and other sedatives in the presence of sleep deprivation or medical conditions known to increase the tendency to fall asleep, such as sleep apnea." t
Simpson RK, Edmondson EA, Constant CF, et al. Transdermal fentanyl as treatment for chronic low back pain. J Pain and Symptom Management 1997; 14:218-224.
Transdermal fentanyl produces significant improvement in pain relief for chronic low back pain when compared to oral opioids, according to this study.
The researchers from the Baylor College of Medicine in Houston studied 50 patients who had chronic low back pain for at least six months and who had used oral opioids for at least that long without satisfactory results. Actively employed patients represented 20%, and the other 80% were unemployed and/or disabled. Each patient was asked to complete a battery of questionnaires including a visual analog scale of pain intensity and other measurements of disability, sleep, and pain relief. Then each patient underwent a nine- to 12-day titration phase with transdermal fentanyl, with patients seen in the clinic every three days while the dose of the patch was increased and the amount of short-acting opioid was decreased.
Once titration was achieved, each patient was maintained on transdermal fentanyl for one month and evaluated weekly for possible adverse reactions. At the conclusion of the one month of treatment, each patient completed the same questionnaires again. The visual analog scale score declined from an average of 79.78 to 44.22 with the fentanyl.
The pain relief scale also declined significantly. "Thus, both instruments clearly demonstrated a highly significant difference in the pain reported before and after transdermal fentanyl use," the authors say. The disability also was significantly reduced and sleep was improved.
Of the 50 study patients, 23 were put back on transdermal fentanyl at the end of the study at the patients’ request. Another 36% said they were considering it, and only 18% said they preferred to continue using oral opioids. Those remaining with opioids cited inadequate pain relief or fentanyl side effects including headaches, light headedness, and skin reactions.
The researchers conclude that "transdermal fentanyl might be superior to oral opioids in limiting the overall disabilities caused by chronic low back pain, including sleep-related problems." t
Lipscomb HJ, Dement JM, Loomis DP, et al. Surveillance of work-related musculoskeletal injuries among union carpenters. Am J Industrial Med 1997; 32:629-640.
Workers who have a longer history as members of their carpentry union are less likely to sustain disabling injuries, according to this study, which also highlights the type of injuries more likely be seen among different types of carpentry specialties.
The researchers studied the health insurance files from the Carpenters’ Trusts of Western Washington, identifying 10,935 active union carpenters (98% men) who worked at least three months of union time during 1989 to 1992. They analyzed the records to determine the part of the body injured, the nature of the injury, the mechanism of injury, and the substance or object associated with the injury. There were 3,050 claims filed for 16 categories of musculoskeletal injuries, of which 38% resulted in paid lost time from work. The highest rate of claims was for back sprains, sprains to the neck and back, and knee sprains. There was a clear trend to more injuries among workers who had been members of the carpentry union for only a short time. Workers who had been members of the union for four years or longer had lower risks for almost all of the musculoskeletal disorders studied.
Women were more prone to sprains
Among older workers, the rates of fractures of the foot were higher, while rates of contusions of the hand and foot were lower. Women had higher rates of sprains, strains, and nerve conditions of the wrist and forearm. Higher rates of injuries to the axial skeleton were seem among carpenters who did predominantly light commercial and drywall work, while pile drivers had lower rates of those injuries. Drywall workers had higher rates of sprains to the ankle and lower leg.
"Union workers may have safer work practices which are learned over time or in training even among individuals who enter the union as journeymen with nonunion carpentry experience, explaining the fact that having been in the union for four years or more was clearly protective for all events," the authors write. "It might be a reflection of different job assignments, with the less skilled workers receiving the more dangerous or physically taxing tasks."
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