A survey to describe sleep-facilitating substances used by Canadian emergency physicians

EM Advances

CJEM 2005;7(2):93-102

Abstract

Résumé

Introduction

Emergency physicians care for acutely ill patients on a 24 hours a day, 365 days per year basis. They work day, evening and night shifts in diverse shifting patterns. Night shifts are especially difficult because they are often busy and night-shift physicians typically work alone. Furthermore, night shifts disrupt normal circadian rhythms; therefore, sleep management is crucial.

Self-medication is one of the strategies used to cope with shift work and the related sleep disruption;^1-5 however, there is no information available on the prevalence of use of sleep-facilitating medications by emergency physicians. The purpose of this survey was to describe the use of sleep-facilitating substances (SFSs) and sleep-facilitating techniques by emergency physicians, and to identify factors associated with their use. Our hypothesis was that most emergency physicians use SFSs in order to deal with sleep disturbances related to shift work.

Methods

In April 2003, a cross-sectional survey and an introductory letter were mailed to all Canadian Association of Emergency Physicians (CAEP) members who had a Canadian postal address. In order to ensure confidentiality, the survey was sent only once and both the survey and the returned envelope were unmarked. The survey was pre-tested and took 3 to 4 minutes to complete. We excluded physicians who worked less than one night shift per month, those who worked less than half time in an emergency department, and those practising outside of Canada. This survey was approved by our hospital's research ethics committee.

The survey elicited information on age, family status, medical practice and sleep habits before and after a night shift (see online e-Appendix 1). Respondents were also asked to describe their use of SFSs or sleep-facilitating techniques to enhance sleep before or after a night shift. Study data included descriptions of the specific substances used (barbiturates, benzodiazepines, antihistamines, other sedative-hypnotics, alternative medications, alcohol or marijuana) and time since last use, stratified in the following manner: more than one year, less than one year, or less than one month.

e-Appendix 1. Cross-sectional survey mailed in April 2003 to all members of the Canadian Association of Emergency Physicians with a Canadian postal address

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Two separate logistic models were used to analyze the data. 1) The first model assessed the relationship between personal and emergency medicine practice characteristics (independent variables) with the use of SFSs before a night shift at any time during their career (dependent variable). 2) The second regression model assessed the relationship of these independent variables with the use of SFSs after a night shift at any time during their career (dependent variable). Variables significantly associated (p < 0.05) with the use of SFSs before (or after) a night shift by univariate analysis were incorporated in a logistic regression model. Interactions were evaluated, and variables were retained if they remained significant at p < 0.05.

Results

Of 1634 surveys sent, 11 were undeliverable; 805 of the remaining 1623 were completed and returned, for a response rate of 49.6%. Of the 805 who responded, 628 (78%) met the study inclusion criteria.

Table 1, Table 2 and Table 3 summarize demographic characteristics, practice variables and SFS use for the study sample, and show the results of the univariate analysis. One hundred and fifty-two (24%) respondents reported using sleep-facilitating techniques other than SFSs to help them sleep before or after a night shift. These techniques included relaxation in 35 cases (23%), reading in 31 (20%), listening to music in 25 (16%), exercise in 18 (12%), and television, white noise or meditation each with 10 (7%).

A total of 215 emergency physicians (34%) had consumed at least one SFS in their career to help them sleep before or after a night shift (Table 4).

Among the 215 users, 26 (12%) always used SFSs before a night shift, 26 (12%) used SFSs most of the time, 27 (13%) used SFSs some of the time, 39 (18%) used SFSs exceptionally, and 97 (45%) never used SFSs before a night shift.

Among the 215 users, 4 (2%) always used SFSs after a night shift, 26 (12%) used SFSs most of the time, 56 (26%) used SFSs some of the time, 71 (33%) used SFSs exceptionally, and 58 (27%) never used SFSs after a night shift.

The most frequently used SFSs were dimenhydrinate, by 100 physicians (47%), zopiclone by 75 (35%), wine by 56 (26%), lorazepam by 54 (25%), diphenhydramine by 54 (25%), beer by 47 (22%) and melatonin by 43 (20%).

One hundred and forty-one emergency physicians (66% of respondents who used SFSs before or after a night shift, or 22% of all respondents) had consumed at least one substance within the past month. The proportion of respondents who reported using SFSs at times other than before or after a night shift among all was: 8 (1%) most of the time, 63 (10%) some of the time and 104 (17%) exceptionally. Seventy-seven percent (447) of the respondents never used SFSs at any time other than before or after a night shift.

Table 5 demonstrates the multiple logistic regression models of variables associated with the use of SFSs before and after a night shift.

Discussion

Our survey demonstrates that a minority (22%) of emergency physicians reported using SFSs before or after a night shift within the month preceding the survey. Overall, 13% regularly use SFSs before night shifts, 14% after night shifts, and 11% at other times. This is a surprisingly low rate of use given the ease of access that emergency physicians have to SFSs.

Sleep disturbance is a common complication of shift work.⁶ Between 40% and 80% of industrial night workers report disturbed sleep compared with 10% to 15% of day workers.⁷ Sleep for shift workers is reduced in length by 1 to 4 hours, with the reduction mainly affecting stage 2 and REM sleep. Our data suggest that most emergency physicians are subject to the same concerns. Our logistic regression analysis suggests that physicians who use SFSs before night shifts are more likely to use them after night shifts and at other times, and that a successful nap before night shift decreases the use of SFSs after the shift.

Age and years in practice were not associated with SFS use. Conventional wisdom suggests that the burden of night shifts becomes greater with age, yet our data do not show higher rates of SFS use among older emergency physicians. Perhaps these physicians have adopted other lifestyle or practice changes to mitigate the impact of night shifts, but these were not evaluated in our study.

Physicians as a group are relatively heavy users of psychoactive medications.^8-10 In one study, 37% of physicians reported sleeping pill or tranquilizer use (within the preceding year) compared to 21% of the general population.⁸ Other investigators have concluded that, despite higher rates of alcoholism than the general population, physicians are not at substantially higher risk of drug addiction.¹¹ The use of SFSs by Canadian emergency physicians is therefore not out of keeping with the use of medications for this purpose by physicians in general.

Emergency physicians' use of SFSs is comparable to other night-shift workers and to the general population. A study from France showed that 15%-18% of nurses working permanent nights used hypnotics or tranquilizers in 1980, 1985 and 1990.¹² Other data from the same time periods showed that 4%-8% of nurses working alternating night shifts (more similar to emergency physician shifting patterns) used hypnotics or tranquilizers; however, this study did not evaluate alcohol, over-the-counter (OTC) medications or alternative medications.¹² In a telephone survey of Detroit residents in the age range of 18 to 45, 26% of respondents reported using SFSs during the last year. Overall, 13% used alcohol and 18% used other medications, including prescription (5%) and OTC (10%) medications.¹³ In the Detroit study, respondents who worked evening, night or rotating shifts used alcohol more than day workers or non-workers, and in a US national survey of the general population, 16%-28% of respondents used alcohol as a sleep aid and 22%-29% used OTC medications.^14,15 In a report on two studies of university students, 7% of respondents used OTC medications as sleep aids and 11% used alcohol (within the preceding year); however, prescription medication and illicit drug use was not specified in that study.¹⁶

Limitations

Although our response rate was excellent for a survey with only one mailing, it is possible that non-respondents had different patterns of SFS use. Further, despite the confidential nature of the study, it is possible that some physicians were reticent to reveal true SFS use. We only evaluated the members of one national association of emergency physicians (i.e., CAEP). Finally, our analysis looked only at correlates of SFSs before or after a night shift. Had we studied use over shorter time periods, our findings may have differed.

Conclusion

Despite having easy access, emergency physicians' use of SFSs appears comparable to other night-shift workers. Emergency physicians who use SFSs before or after a night shift are more likely to use them at other times. Successful sleep before a night shift decreases the use of SFSs after the night shift.

Supported by a grant from the Canadian Association of Emergency Physicians.

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