– Used in the treatment of short-term insomnia and in the treatment of the root cause of long-term insomnia
What are the main lines of insomnia medication?
The main lines of medication for insomnia are based on recommendations. The starting point is treatment according to the cause of insomnia. Most commonly used drugs in the treatment of short-term temporary insomnia are benzodiazepine-like medicines that act through the GABA system, called zopiclone or zolpidem (so-called Z medicines). They do not alter the structure of sleep as much as benzodiazepines. Melatonin can be used especially in the treatment of insomnia in elderly patients and, on the other hand, in delayed sleep phase syndrome patients. Of the traditional benzodiazepines, temazepam is the most commonly used. At very low doses, doxepin, trimipramine, amitriptyline, and mirtazapine act as histamine-1 antagonists and increase deep sleep. They have grown in popularity as sleep-enhancing drugs.
In long-term insomnia medication, treatment is aimed at the root cause of insomnia. Non-drug therapies are always preferred and have a better benefit-risk balance than drug therapy. Benzodiazepines and anticholinergics, as well as strong antihistamines and antipsychotics, should be avoided where possible in the long-term treatment of insomnia. In older people in particular, the disadvantages of long-term use of traditional sleeping pills outweigh the benefits on average.
What are the possibilities and dangers of drug treatment of insomnia?
In studies of the treatment of insomnia in people over 60 years of age, cognitive impairment and daytime fatigue were more common in the groups that were using sleeping pills than in the reference groups. In summary, the physician should treat an average of 13 patients to achieve a significant improvement in sleep quality and length. On the other hand, only 6 patients were needed to achieve various cognitive impairments with benzodiazepines.
- The disadvantages of long-term use of traditional sleeping pills over the age of 60 outweigh the benefits. For example, the artificial sleep provided by benzodiazepines does not match to natural sleep.
An exception may be people with rare idiopathic insomnia, who are often sensitive to various side effects of the drug, but who can cope with very little sleeping medication (the dose is assessed individually by the doctor) without problems with tolerability, drug dependence or significant side effects.
Sedative antidepressants may also be suitable for the treatment of insomnia. In the primary treatment of insomnia, the doses are very small compared to the doses used to treat depression. For example, doxepin often acts best as a sleeping pill at doses well below 10 mg, mirtazapine well below 15 mg, and trimipramine at doses below 25 mg. When higher doses of doxone or amitriptyline are used, antischolinergic side effects should be considered. For the same reason, older sedatives (sedative neuroleptics) are not recommended.
Neurological and neuropsychiatric patients, the elderly, and the mentally handicapped may be very sensitive to the memory-impairing effects of anticholinergic drugs. They relax the muscles, which makes it easier to fall asleep and so the person suffering from insomnia can experience them, especially at the beginning of treatment, as “good sleeping pills”. However, there is no proper evidence of the benefits of these potent central nervous system drugs, and the disadvantages clearly outweigh the benefits in the treatment of insomnia.
In the past, dicyclamine, or dicycloverine hydrochloride, was used to treat colic problems. Now it has been removed from the pharmaceutical market due to disadvantages, but it can still be seen used in some places. Dicycloverin impairs memory and can cause cardiac arrhythmias and sleep apnea. It can also cause hallucinations and develops addiction fairly quickly.
People with ADHD are often low-key and tired, and for them, stimulant medication can sometimes have a beneficial effect on sleep as well. If you have significant anxiety underlying insomnia, taking SSRIs or SNRIs (antidepressants) in the morning may help. Potential depression must be properly identified and treated.
When using current sleeping pills, it should be remembered that medications often have a long duration of action, most often requiring a 7-hour withdrawal period. As the dose increases, the withdrawal period may be extended to more than 14 hours. A side effect may be the rebound phenomenon, which means that after stopping sleeping pills, sleep disorders may return transiently more severely, resulting in anxiety and continued insomnia. Other side effects include slowed reaction times, memory problems, and paradoxical reactions such as confusion, bias, diplopia, and speech disorders (dysarthria). Different drugs have interactions that should be avoided. Some antidepressants, antibiotics and antifungals, for example, cause bad interactions. Discuss about the use of sleeping pills with your doctor and tell him or her about your experience.
- In the treatment of insomnia, the best results are often achieved by increasing the daytime alertness and physical and mental hobbies.
If a person suffering from insomnia begins with sleep medication without better clarifying the matter, there is a risk of getting into a cycle where too much sedation in the evening causes a decrease in alertness and cognitive function the next day. As a result, anxiety increases the next night and there is no natural fatigue. This makes it easy to end up in a cycle with sleeping pills.
Melatonin in the treatment of insomnia
Melatonin is not an actual sleeping pill, but a so-called time-biological drug, or chronobiotic.
It is also called night hormone and dark hormone. Melatonin is secreted from the pineal gland in the brain. It is also made chemically.
Melatonin helps to synchronize the body’s internal clock by regulating the circadian rhythm. As a result, body temperature and alertness level decrease, which improves falling asleep and sleep quality, and prolongs night sleep.
Melatonin, which helps you fall asleep, is an effective remedy for long-term or primary insomnia (persistent insomnia for at least one month due to neither a mental disorder nor an organic disease) and in the treatment of insomnia due to time difference stress / jet lag. The recommended use of melatonin is insomnia in people over 55 years of age. In practice, melatonin has also been shown to be useful in the treatment of younger special groups.
Melatonin is a familiar preparation in biological rhythm pacing, for example, when the sleep-wake rhythm is disturbed and there is a time difference stress or a delayed sleep phase syndrome. When treating time difference stress (jet lag), care should be taken in the timing of taking the drug: it is taken after arrival in the destination country / home country on 2-4 evenings at around 10 pm (local time).
Short-acting melatonin has been available for several years. A long-acting, slowly absorbed depot preparation (depot melatonin) is also on sale today. The half-life of short-acting melatonin is about 40 minutes, which makes it suitable, above all, for falling asleep. If the problem is intermittent nighttime sleep, a long-acting preparation may be a better option.
The dosage of melatonin is individual. An effective dose of regular melatonin is 0.5 to 6 mg. The dose of depot melatonin is usually 2 mg and is intended primarily for those over 55 years of age whose melatonin secretion has already decreased. It is therefore a form of substitution treatment. Adults should take short-acting melatonin usually between 8 pm and 11 pm and long-acting depot melatonin between 8 pm and 10 pm.
- Melatonin regulates a person’s natural sleep-wake rhythm. It is excreted in the brain at night, during the dark hours of the day.
Instructions for use of sleeping pills
– Follow your doctor’s instructions when taking medicines
– Avoid drinking alcohol while taking sleeping pills. Alcohol and sleeping pills when taken at the same time reinforce each other’s effects and can lead to adverse effects.
– If you are taking other medicines at the same time, tell your doctor. For example, antihistamines or antidepressants used in combination with sleeping pills potentiate each other’s effects.
– Before taking sleeping pills, make sure you can sleep properly. Awakening in the middle of the drug effect is not desirable, as normal functioning may then be temporarily impaired.
– Sometimes sleeping pills can adversely affect performance even after waking up. Therefore, monitor your performance and do not drive, for example, if you feel tired.
– If you are taking short-acting sleeping pills or sleep aids, remember that they work very quickly. Therefore, take the medicine only immediately before going to bed, preferably in bed.
– If you have been taking sleeping pills for a long time and stop taking the medicine suddenly, your insomnia may get worse over the next few days. However, this is a harmless and transient phenomenon. If you have been taking sleeping pills for more than a week, it is recommended that you reduce the dose gradually when you stop taking the medicine.
– Sleeping pills should not be used during pregnancy or breast-feeding except in exceptional cases where it is best to consult a doctor.
– It is good to remember that stopping long-term sleeping medication can take months or even more than a year.
How to get off sleeping pills?
Prolonged use should be stopped when the original cause of insomnia has disappeared and when insomnia can be expected to be due at least in part to the use of sleeping pills or the patient suffers from insomnia even though he is taking sleeping pills. Discontinuation of use of sleeping pills should be considered whenever you are motivated to stop taking medication.
Often the medication is discontinued gradually: 2 weeks – 3 weeks – 6 months. Often, stopping the last half or quarter of a drug is the most difficult. If necessary, supportive care (possibly eg trimipramine, mirtazapine or valproate) may be sought. Cognitive therapy is also used as a support. If insomnia is caused by depression, the underlying disease must be treated.
Physicians should be vigilant with regard to specifically monitored sleeping pills and medications used to treat anxiety in an insomnia patient, such as midazolam, triazolam, clonazepam, lorezepam, and alprazolam. If any of the above medications are used, the physician must inform the patient in advance of the risk of dependence and that withdrawal symptoms may occur during discontinuation. The patient needs to know that after just a week of use, discontinuation should be done gradually.
Findings about sleep and sleeping pills
If insomnia reflects depression, treatment should include an antidepressant drug such as amitriptyline, doxepin, mianserin, or trazodone and mirtazapine. Old antidepressants affect natural sleep, but their use is sometimes associated with, for example, increased intraocular pressure and cardiac arrhythmias.
Therefore, their use is less common in the elderly. New drugs are being developed to treat depression and insomnia.
Sleeping pills can interfere with sleep. It must be remembered that waking up at night, restlessness and confusion may result from the use of sleeping pills. The best option is often to sleep without sleeping pills.
Unfortunately, non-sleeping pills treatment is more laborious than prescribing sleeping pills. The physician should inform the patient about the importance of nighttime sleep and the causes of insomnia. In this case, most understand why a poorly slept night’s sleep may be a better solution than constant use of sleeping pills. The patient should also be informed that sleeping pills can be used from time to time without concern.
Long-acting sleeping pills are generally not suitable for the treatment of insomnia. They are mainly used to treat anxiety. Medications increase daytime fatigue.
Medium-acting sleeping pills are used when sleep is intermittent. The drugs act fairly quickly and their effect lasts until morning. The side effects that occur the next day are not as severe as with long-acting sleeping pills.
Short-acting hypnotics, as the name implies, work so that a person falls asleep in the evening. These drugs therefore do not help with actual insomnia. If the person taking the sleeping pill wakes up at night, he may get out of bed but not remember any events in the morning. Hypnotics are the same thing as short-acting sleeping pills.
Benzodiazepine derivatives are effective in the treatment of short-term insomnia. The effect of the drug is on the central nervous system. Medications relieve anxiety, soothe, relax muscles and prevent cramps.
Benzodiazepine-like drugs accelerate falling asleep and have a calming effect, relieving anxiety. In addition, they relax the striated muscles. The most commonly used drugs are zolpidem and zopiclone.
- Benzodiazepines have a detrimental effect on memory, which should be borne in mind, especially in the elderly, so they must be used with caution.
What are the effects of insomnia on ability to work and drive?
Insomnia is typically considered an ailment of a conscientious worker. A particular risk of developing chronic insomnia is in patients who have recovered from a neurological disease and return to work with a disability. If their energy level has not returned to normal, performance will be insufficient.
If work duties and work requirements do not match the changed performance level, easily develops work-related anxiety and stress, which impairs sleep and thereby further performance. Patients retiring on sick leave, on the other hand, are at risk of being depressed by the emptiness of life.
- Insomnia increases the risk of incapacity for work in proportion to depression.
One study found that insomnia increases the risk of incapacity for work, especially when there is concomitant musculoskeletal disease or mental disorder. It is further known that prolonged sleep deprivation can cause intoxication -like state, especially in demanding work tasks. Sleep deprivation exposes you to accidents and mistakes. Insomnia can be a significant barrier to work ability, which is often overlooked. In assessing the effect of insomnia on ability to work, clinical assessment of functional capacity is crucial. In particular, it is appropriate to properly map out errors and near misses in daily activities, work and traffic, as well as change in other social relations and hobbies.
In terms of driving ability, insomnia per se is usually not a problem. A person with insomnia is typically overactive. On the other hand, prolonged insomnia can cause attention deficit disorder, nervousness, and impaired judgment, which increase the risk of a traffic accident. The biggest problem is with the use of sleeping pills. For example, when a patient over the age of 65 has taken 7.5 mg of zopiclone as a medicine, their ability to drive may be impaired 10 hours after taking the medicine. The safe withdrawal period after temazepam and zolpidem is likely to be 7-8 hours. The effect is strongest at the beginning of sleep medication. The sleep medication user should be aware of these withdrawal periods. If you have taken more than the recommended dose of sleeping pills, do not drive a car!