The Use of Sleeping Tablets

Over the last 20-30 years the prevailing view is that using medication to fall asleep is a ‘bad thing to do’. People have been made to feel bad about using sleeping tablets. This is often the result of misunderstanding and a negative attitude on the part of authority and to some groups of health professionals.

The use sleeping tablets is like the use of any other medication. If used in the appropriate circumstances and under proper supervision they are safe, effective and appropriate.

Over the last 20-30 years the availability of medications that are more effective and safer makes the use of sleeping tablets a much better strategy when appropriately used. Proper use of medications to promote sleep is similar to the use of painkillers when someone has pain. You can use paracetamol or aspirin in someone who has a headache for a few days. In the same way you can use sleeping tablets when the person is particularly stressed and finding it difficult to relax.

The medications that can be used are listed at the end of this chapter. In particular short acting benzodiazepine such as Temazepam or similar that works between 8-12 hours, and therefore minimizes any spilling effect during the day, can be used safely for a few days when necessary.

The new group of sleeping tablets which are labeled the ‘Z’ sleeping tablets (zolpidem, zopiclone and zapleton) are also safe. Some of these medications have received bad publicity in the media because they can increase the risk of sleepwalking and other movement during sleep. This is true but is a relatively rare event considering the amount of medication used worldwide. The Z medications seem to have some interesting features. Firstly they have a very short action, between 4-6 hours, and therefore the risk of side effects during the day is small. The risk of rebound (worsening of insomnia) when the person stops the medication is also small.

It is interesting that the media focuses attention on the ‘Z’ medications in terms of increased motor activity during sleep but they totally ignore the fact that most of the antidepressants available nowadays can also increase motor activity and a simple molecule like Lithium for example can also increase the risk of sleep walking.

Of course sleeping tablets do not cure insomnia but they may be helpful at times.

 The following are common indications:

Transient insomnia (insomnia which lasts a few days or a week or so). The person is usually aware of the reason for the insomnia and the use of sleeping tablets may help the person resting and therefore minimizing the effect of insomnia on daytime functioning.

Chronic insomnia refractory to other forms of treatment. There are some cases where insomnia has been present since childhood (childhood onset insomnia) in which the use of medication may have to be continued long terms; however these are rare situations. In patients in whom cognitive –behavioral therapy is not successful (up to 30%) sleeping tablets may need to be used, at least intermittently (e.g. 3-4 days a week).

Chronic insomnia in the presence of other sleep problems such as restless leg syndrome or anxiety disorder. In these cases the use of benzodiazepine (e.g. temazepam, clonazepam) has a role in improving the underlying primary sleep disorder (restless legs), anxiety and insomnia.

Sleeping tablets are preferably avoided or to be use with extreme care in the following situations:

In pregnancy and breast feeding. 

People with severe obstructive sleep apnoea. 

People with a previous history of recreational drug abuse including alcohol. 

People with certain occupations such as commercial drivers, heavy machinery operators, people who are on-call and may be called to attend their work in the middle of the night. However in these groups insomnia itself can be detrimental and the benefit of improving sleep length and quality may overcome the potential side effects of using sleeping tablets.

In the elderly patients a smaller dose needs to be considered.

Generally long-term use of sleeping tablets is not to be recommended but in conjunction with the other strategies explained in this chapter can help the person overcome insomnia. There is evidence that use of sleeping tablets can be effective for up to 12 months, although the “usual” recommendation is to be used for no more than four weeks.

The current sleeping tablets available are listed in the table 2. It is preferable to use medications that have a short length of action between 2-8 hours so that there is no after effect during the day.

Risk associated with taking sleeping tablets

Like with many other medications certain symptoms may occur such as light-headedness, dizziness and sometimes unsteadiness particularly if the medication is in excessive dosage.

Daytime sleepiness. This is seen predominantly with medications that have a long action. The most recent medications such as temazepam, triazolam and zolpidem and zopiclone have short action and the probability of daytime sleepiness is low.

Rebound insomnia. This refers to the worsening of insomnia once the medication has been stopped. This is usually seen in people who are on sleeping tablets for a long time and stop suddenly. The rebound insomnia, however, is only of short duration. It should also be noted that rebound insomnia occurs even when the person is given placebo (a dummy tablet).

Daytime anxiety. With some medication, particularly the benzodiazepine (Triazolam) some people may experience an increase level of anxiety during the day due to “rebound” effect.

Another concern with the use of sleeping tablets is possible disturbance in body balance which can increase the risk of fall. This risk seems maximal in the first few days of use. The longer the action of the sleeping tablet, the more it is likely to affect balance during the day. However even medications with shorter action could increase the risk of falling in patients who get up in the middle of the night. It should however be noted that insomnia itself may lead to increase in risk of lack of balance. Therefore in patients with chronic insomnia the overall effect depends on the benefits from improving insomnia versus the risk of side effects.

The concern about the increase risk of motor vehicle accidents in patients on sleeping tablets has also been raised. However sleep disruption due to severe insomnia may also lead to increased risk. Again in prescribing sleeping tablets the benefit versus risk need to be taken into consideration.

Over the counter sleep aides

There are many over the counter preparations used for insomnia, usually antihistamine (e.g. Diphenhydramine 25-50mg, Snuzaid™, Doxylamine 25mg, Restavit™), which are frequently used and are effective. However, they cause daytime drowsiness and sedation, dry mouth, voiding difficulty and occasionally increase intra-ocular pressure (glaucoma). Therefore this kind of preparations is best avoided.

‘Natural’ products

There are a variety of natural products available such as Valerian, chamomile, lemon balm, hops, passion flower, Kava Kava, lavender.

Valerian is an ancient remedy for insomnia. Valerian contains a substance, which is similar to benzodiazepine (Valium), which may explain a partial effect as a sleeping promoting agent. It is also said that it may increase the secretion of melatonin.

The use of valerian should be continued for a few weeks before a beneficial effect can be experienced. Using valerian for a few nights does not appear to be beneficial.

The limited experience with Valerian suggests no significant side effects and no significant withdrawal symptoms. There is some concern about the potential effect of some of the metabolites of Valerian in the experimental setting and therefore it is preferable to avoid valerian during conception and during lactation.

Kava Kava is a common beverage in the South Pacific. It is said to have an anti-anxiety effect and a kind of action which that may resemble benzodiazepine. There are a variety of formulations and different dosages. One possible concern of the side effects of Kava Kava containing medication is liver failure. Another side effect of concern is discoloration of the skin with a yellowish hue.

Lavender is also used as a relaxant, often as aromatherapy. The effect of lavender on sleep is not well documented but it may have a beneficial effect indirectly through reducing the level of anxiety.

Many other ‘natural’ sleep aids are available such as chamomile, lemon balm, hops, passionflower and skullcap. There is very little evidence that they improve sleep. However, in individual cases they may be beneficial.