Why are doctors reluctant to prescribe sleeping tablets?
Doctors avoid prescribing sleeping tablets if possible due to the problems sleeping tablets can cause. In particular, the concern is that you could become dependent on sleeping tablets or addicted to them. Possible problems when taking sleeping tablets include the following:
- Drowsiness the next day. You may not be safe to drive a vehicle or to operate machinery. Evidence shows people who take sleeping tablets are more likely to be involved in road traffic accidents.
- Clumsiness, drowsiness, and confusion in the night (if you get up). These can occur - for example, if you have to get up in the night to go to the toilet. You may fall over and injure yourself. Some people have fallen down stairs due to the drowsiness caused by sleeping tablets. (Older people who take sleeping tablets have an increased risk of breaking their hip, as the result of a fall.)
- Risks. One study suggests that people who use sleeping tablets for a long time are more likely to develop dementia. (This has not been proven yet.)
- Tolerance. If you take benzodiazepines and Z drug sleeping tablets each night, your body becomes used to them. This means that, in time, the usual dose has no effect. You then need a higher dose for it to work. In time, the higher dose does not work and you need an even higher dose, and so on. It can take as little time as just a few days for tolerance to develop.
- Dependence. Some people become dependent on benzodiazepines or Z drugs. This means that withdrawal symptoms occur if the tablets are stopped suddenly. Withdrawal symptoms include anxiety, shaking, or just feeling awful. If you have taken a benzodiazepine or Z drug regularly for more than two to four weeks, you will need to come off it gradually, to avoid withdrawal symptoms.
- Addiction. Some people who are dependent on benzodiazepines or Z drugs may become addicted to them. If you are addicted to a medication, you have uncontrollable cravings for it and feel a need to take it. This can happen even after you have slowly withdrawn from it so that you are no longer dependent. Tolerance, dependence and addiction are different things. Some types of people seem more likely than others to become addicted to substances.
In some cases, however, sleeping tablets may be very helpful. In short courses for time-limited problems, they are safe to use. For example, if you have had a sudden shock or bereavement, sleeping can be a problem. A short course of sleeping tablets (for a week or two) may help you cope better in the daytime. Or if you have jet lag and are struggling with re-setting your internal time clock. Doctors advise that you take no more than two weeks of sleeping tablets at a time. If you just take the tablets for a week or two, you will not become dependent on them.
Are there different types of sleeping tablet?
Benzodiazepines and Z drugs
Benzodiazepines and Z drugs are sometimes used as sleeping tablets. Benzodiazepines include temazepam, loprazolam, lormetazepam, and nitrazepam. They are only available on prescription. Other related drugs called zaleplon (no longer available in the UK), zolpidem and zopiclone are also sleeping tablets. Strictly speaking, they are not benzodiazepines. They are known as the Z drugs. However, they act in a similar way (they have a similar effect to benzodiazepines on the brain cells).
These medicines are commonly used to treat allergies such as hay fever. However, drowsiness is a side-effect of some antihistamines - for example, promethazine. This 'side-effect' is useful in some people who have difficulty sleeping because of their allergy. An antihistamine is the active ingredient of some sleeping tablets that you can buy from pharmacies, without a prescription. Antihistamines are not as powerful as benzodiazepines or Z drugs at causing sleep. Also, they may cause a 'hangover' effect and some drowsiness in the morning. They may also cause rebound insomnia if you take them for a long time. For these reasons, current UK guidelines do not advise the use of antihistamines to be used solely as a sleeping tablet.
Melatonin is, strictly speaking, not a 'sleeping tablet'. Melatonin is a naturally occurring hormone made by the body. The level of melatonin in the body varies throughout the day. It is involved in helping to regulate the daily cycles (circadian rhythms) of various functions in the body. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia. The recommended duration of treatment is for three weeks to start with. If helpful, it can be used for a maximum of ten weeks in total.
In some countries melatonin is used to help with sleep problems related to jet lag. In the UK it is not currently licensed for this.
Chlormethiazole, chloral, and barbiturates are old-fashioned sleeping tablets. They are not commonly used these days, as benzodiazepines and Z drugs are usually preferred. Certain antidepressants are sometimes used to help with sleep, particularly if depression or anxiety is thought to be causing the problem.
What is the alternative to sleeping tablets?
Try to work out the reason for your sleeping difficulties. Where possible, correct this.
Your doctor or nurse may give you advice on how to tackle poor sleep naturally. They may also refer you for a type of talking therapy called cognitive behavioural therapy (CBT). CBT is a type of brain-training, which aims to teach your brain how to fall asleep.
If a sleeping tablet is prescribed
If your doctor prescribes a benzodiazepine or Z drug as a sleeping tablet for you, it will usually be only for a short time (a week or so). This is to help you get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents either tolerance to or dependence on the tablet from developing.
What if I am already taking a sleeping tablet regularly?
For various reasons, some people have become used to taking a benzodiazepine or Z drug sleeping tablet every night. As a rule, if you are taking one of these sleeping tablets each night, you should consider reducing or stopping them. However, in some people, problems of tolerance or dependence (see above) mean that it can be difficult to stop the tablet suddenly.
If you want to reduce or stop benzodiazepine or Z drug sleeping tablets, it is best to consult a doctor or nurse for advice. The sort of advice may include the following:
- Do it gradually and cut the dose down a little at a time. A switch to a different benzodiazepine (diazepam) may be advised. This is because it is easier to reduce the dose of diazepam gradually than it is with other benzodiazepines or Z drugs.
- It is best to wait until any life crisis has passed and your level of stress is as low as can be.
- Consider stopping the tablets whilst on holiday, when you have less pressure from work, family, etc.
- You are likely to have a period of worse sleep when you stop the tablets. Try to anticipate and accept this.
- Advice on coping strategies, and tips on how to improve your sleep pattern naturally.
See separate leaflet called Stopping Benzodiazepines and Z Drugs. However, stopping benzodiazepine or Z drug sleeping tablets is not practical in every case.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.
Further reading and references
Insomnia - zaleplon, zolpidem and zopiclone for the management of insomnia; NICE Technology Appraisal Guidance, April 2004
Insomnia; NICE CKS, April 2015 (UK access only)
Consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders; British Association for Psychopharmacology (2010)
Buysse DJ, Germain A, Moul DE, et al; Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 May 23171(10):887-95. Epub 2011 Jan 24.
Taibi DM, Landis CA, Petry H, et al; A systematic review of valerian as a sleep aid: safe but not effective. Sleep Med Rev. 2007 Jun11(3):209-30.
Sleep diary; American Academy of Sleep Medicine
Buysse DJ; Insomnia. JAMA. 2013 Feb 20309(7):706-16. doi: 10.1001/jama.2013.193.
Luik AI, Kyle SD, Espie CA; Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review. Curr Sleep Med Rep. 20173(2):48-56. doi: 10.1007/s40675-017-0065-4. Epub 2017 May 8.
Lemoine P, Zisapel N; Prolonged-release formulation of melatonin (Circadin) for the treatment of insomnia. Expert Opin Pharmacother. 2012 Apr13(6):895-905. doi: 10.1517/14656566.2012.667076. Epub 2012 Mar 19.
Qaseem A, Kansagara D, Forciea MA, et al; Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Jul 19165(2):125-33. doi: 10.7326/M15-2175. Epub 2016 May 3.
Sateia MJ, Buysse DJ, Krystal AD, et al; Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 1513(2):307-349. doi: 10.5664/jcsm.6470.
Hale L, Guan S; Screen time and sleep among school-aged children and adolescents: a systematic literature review. Sleep Med Rev. 2015 Jun21:50-8. doi: 10.1016/j.smrv.2014.07.007. Epub 2014 Aug 12.
Chang AM, Aeschbach D, Duffy JF, et al; Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci U S A. 2015 Jan 27112(4):1232-7. doi: 10.1073/pnas.1418490112. Epub 2014 Dec 22.
Coming up to ten years on this amazingly horrible drug.I was given it after being awake for 6 days straight, I was told it was not addictive and was given 3 months supply by the NHS psychotherapist.I...dhmc
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