Sleep Impairment
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Most benzodiazepines have sedative and hypnotic properties, but only five are marketed as hypnotics. All five reduce sleep-onset latency, decrease number and duration of nocturnal wakings, and increase total sleep time and sleep efficiency with varying degrees of effects.
Several nonbenzodiaepine hypnotics are currently used in the U.S. or under development or available in other countries. Two are mentioned here:
Most are effective with short-term use. Not much data is available on long-term efficacy. They may be appropriate when severe insomnia is associated with underlying sleep disorder, acute medical condition (pain), or some psychiatric disorders.
Problems associated with use: alteration of sleep stages, daytime residual effects, rebound insomnia, anterograde amnesia, dependence, cognitive and psychomotor impairment, drug “hangover”.
Benzodiazepines are contra-indicated in: pregnant women, substance abusers, sleep apnea patients, people who may unexpectedly be called on to duties at night. They should not be used when major depression with suicidal risk is present. It is usually advisable to treat underlying psychiatric conditions rather than insomnia.
Long-acting drugs produce more daytime sleepiness and greater impairment of waking performance than short-acting ones.
Overall, there is little evidence to suggest that the performance decrements attributable to hypnotic use are compensated for by improved sleep. Drug therapy alone is usually not successful in treating chronic insomnia.
Rebound from use tend to add to anxiety and belief that the person can’t sleep without medication.
Clinical situations in which short-term use of sleeping aides may be helpful:
For persistant insomnia, hypnotic medications should be used as adjuncts (rather than primary resource) to a main therapeutic endeavor (behavioral therapy, cognitive therapy, sleep hygiene).
Dependency on benzodiazepines can be both psychological and physical. Tolerance develops so the therapeutic dosage doesn’t work any longer and the temptation is to increase dosage, or to keep using the drug even though it isn’t working.
Because insomnia increases temporarily upon ceasing use of benzodiazepines there is a tendency to give up when trying to quit using the drug. It is important to realize that if you have been taking benzodiazepines that insomnia will return for a little while as you stop using that drug. Ask your doctor to review the process of eliminating use of benzodiazepines with you, so you will be prepared.
If you’ve been on an intermittant schedule (take as needed) you are likely to be more reliant on the drug, even if you don’t take them every night.
Many people have a misperception of sleep-wake cycles which influences their drug use. Benzodiazepines tend to increase stage 2 sleep but reduce stage 3 and 4 sleep which is considered to be the most restorative. You need stage 3 and 4 to renew your body. While you may not be growing anymore, there are still growth hormones released that help your body heal and refresh for the next day. Stage 2 is the least necessary stage of sleep, it tends to be left out when a person is making up for being significantly sleep-deprived.
Set goals. Write down your planned schedule of tapering off that you have developed with your doctor, week by week. Taper off according to recommendations of product. Some recommend tapering at the rate of 1 therapeutic dose per week.
If you have been allowed intermittant use of the drug, have your doctor stabilize you at a lower dose at a regular interval. You many need to realize that the link between sleeplessness and drug-taking isn’t as helpful as you think. Be sure to check with physician or pharmacist in designing a safe withdrawal schedule. Some heavy users will need in-patient de-tox.
You doctor may consider switching from a short to a long-acting medication to make use of built-in tapering action which may minimize rebound effects.
Introduce drug-free nights. Have nights in which you don’t use any sleeping medication at all. Weekend nights (or non-working nights) are the best to start.
Educate yourself and learn about withdrawal, rebound symptoms and their transiency. Be honest about your motivation to discontinue use, If you don’t want to stop, it will be harder to stop. Be sure to use counseling to help with emotional or cognitive aspects.
Tricyclic antidepressants with sedative effects are recommeded when insomnia is associated with an affective disorder (depression). For this they are better than benzodiazepines especially when there is a suicide risk.
As a general rule, insomniacs with major depression should be told to take the entire dosage of antidepressant at bedtime in order to maximize the sedative effects.
Antidepressants have a lower potential for abuse or dependency but higher drug interaction than with benzodiazepines. You should check carefully with your physician and/or pharmacist to learn about interactions with other drugs that you may be taking.
More energizing antidepressants may worsen sleep difficulties (protriptyline, fluoxetine). Antidepressants suppress REM in people with major depression. There is some research that shows that suppressing REM in people suffering major depression is a help, that for some reason they are getting too much REM sleep and so benefit from the lesser amounts they get when taking these drugs.
Antihistamine is present in most over-the-counter sleep aides. The side-effect is drowsiness, so people use them to promote sleep at night. There appears to be little actual beneficial effects on sleep. There has been very little research attention, and their effect beyond placebo is doubtful.
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