Beyond Policy Interventions: Addressing the Persistence of Hypnotic Use and Polypharmacy in Japan's Aging Population

I read with great interest the article by Kimura et al. regarding the impact of medical fee revisions on long-term hypnotic prescriptions in Japan 1. While the authors conclude that policy interventions significantly redirected prescription trends toward a decline, a more nuanced interpretation is required. Evidence from additional nationwide databases and disparate analytical methodologies indicates that the phenomenon of hypnotic utilization among older population persists as a substantial clinical concern. While Kimura et al. employed interrupted time-series (ITS) analysis to demonstrate a slope change in benzodiazepine (BZD) and Z-drug prescriptions following April 2020, other studies suggest that these policy effects are limited or inconsistent 2. Moreover, while the proportion of patients receiving three or more drugs in certain categories decreased following earlier revisions, BZD receptor agonists (BZRAs) were notably resistant to these reductions 3. The decline reported by Kimura et al. may obscure the absolute volume of BZRA use that persists in older adults. A recent analysis of claims data reveals that prescriptions for BZD medications remain elevated in older populations compared to younger cohorts 4. Although data from university hospitals demonstrate a decline in BZRA proportions among individuals aged 75 and over, this trend emerged as early as 2015. This suggests that clinical guidelines, rather than the 2020 fee revision alone, may be the primary driver of this phenomenon 5. In addition, regional variations in prescription amounts are significantly associated with the density of medical clinics and socioeconomic factors 6. These findings suggest that restrictions alone cannot address the root causes of over-prescription. The transition toward orexin receptor antagonists (ORAs) and melatonin receptor agonists (MRAs) is frequently characterized as an enhancement in safety. Nevertheless, the implementation of these novel medications has not invariably led to the eradication of improper prescribing habits. While there is evidence of ORAs' use in short-term cases, concomitant use remains prevalent. A substantial correlation has been identified between the practice of administering multiple hypnotics concurrently and the subsequent prescription of prolonged treatment regimens 7. In many cases, BZDs remain a frequent treatment option for hospitalized patients, and there is a risk that novel hypnotics are being added to existing BZD regimens rather than replacing them 8. A study revealed that approximately one-third of outpatients prescribed sleep medications were also receiving polypharmacy 9. It is imperative to address a critical gap in the current evidence regarding patient outcomes and healthcare economics. While Japanese policies have been effective in reducing average doses and decreasing suicide attempts by overdose, they have not been sufficient to significantly reduce the prevalence of long-term (12 months or more) hypnotic use. Moreover, restrictions can be a double-edged sword; premature discontinuation of treatment in cases of treatment-resistant insomnia may result in withdrawal or rebound insomnia, leading to an increase in emergency visits. From an economic perspective, the substitution of older medications such as prescription sleeping pills with newer drugs like ORAs, which are more modern BZD alternatives, may present certain financial challenges. Subsequent research endeavors should prioritize the examination of whether policy-induced shifts in the prescription of sleep medications are associated with alterations in clinical outcomes, including the occurrence of falls, fractures, and cognitive impairment. If the policy proves effective, a concomitant decline in adverse events should be observed. In addition, a longitudinal approach is necessary to determine the percentage of patients who are able to discontinue BZDs and transition to ORAs or MRAs. This approach will also facilitate the assessment of the extent to which BZD-related adverse events can be eliminated as a result of the switch. Furthermore, it will allow for the determination of whether the benefits outweigh the increased costs associated with the switch. As primary care physicians rarely employ non-pharmacological interventions such as cognitive behavioral therapy for insomnia (CBT-I), there is a risk that institutional pressure is simply replacing one pharmacological risk with another 10. The apparent decline in hypnotic prescriptions in Japan may be a superficial reflection of shifting drug classes rather than a fundamental change in the management of insomnia. A definitive conclusion regarding the impact of these policy interventions on the quality of geriatric care in Japan remains elusive without a rigorous correlation between prescription trends and patient safety metrics, as well as economic sustainability. All aspects of this work were carried out by the sole author. The author has nothing to report. The author has nothing to report. The author has nothing to report. The author has nothing to report. The author declares no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.