Sleeping tablets

Are sleeping tablets bad for you?

In particular, the concern is that you could become dependent on sleeping aids 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 due to the sedating effect. 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 middle of the night to go to the toilet. You may fall over and injure yourself if you feel sleepy. 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 sleeping medicine such as benzodiazepines and Z drug sleeping tablets to treat insomnia 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 mental health problems such as 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 This can happen even after you have slowly withdrawn from it so that you are no longer dependent.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.

How do sleeping tablets work?

Sleeping tablets work either by a general affect on the brain to promote drowsiness or by directly binding with receptors in the brain to cause sleepiness or relaxation. There are different types of sleeping pills that work in different ways, but all generally affect the brain in some way to promote sleep. It is also thought that there is an additional placebo affect, which means that just by taking the tablets, you may feel more relaxed and positive about getting to sleep, and therefore more likely to get a better night's sleep.

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).

Antihistamines

These medicines are commonly used to treat allergic reactions 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

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 sleep disorders such as long-term 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.

Other medicines

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.

Patient picks for Medicine information

Treatment and medication

Pharmacy First - getting the most from your pharmacist

It's World Pharmacy Day and we explain when you can visit a pharmacist to receive advice and treatment for some simple illnesses, instead of going to see your doctor. Read here about the NHS Pharmacy First scheme, what conditions you can go directly to your pharmacist about, and what else you need to do.

by Lawrence Higgins

Treatment and medication

Oral steroids

Steroid medicines (sometimes referred to as corticosteroids) are man-made (synthetic) versions of steroid hormones produced by the body. There are several different forms of steroid medicines. The form discussed in this leaflet is the tablet form, taken by mouth, called oral steroids. Other types of steroids include creams, ointments, injections, inhalers and sprays. These are discussed in the separate leaflets called Topical steroids (excluding inhaled steroids), Topical steroids for eczema and Asthma inhalers.

by Dr Pippa Vincent, MRCGP

What is the alternative to sleeping tablets?

Try to work out the reason for your sleeping difficulties and identify any specific factors that counter sleep. Where possible, correct any or all of these factors.

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 and stay asleep.

See also the separate leaflet called Insomnia (Poor Sleep).

Do I need a prescription for sleeping tablets?

If your doctor or pharmacist prescribes a benzodiazepine or Z drug as a sleeping tablet for you, it will usually be only short-term (a week or so). This is to help you get over a particularly bad patch and get a good night's sleep. 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.

Can you take sleeping tablets every night?

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 the separate leaflet called Stopping Benzodiazepines and Z Drugs. However, stopping benzodiazepine or Z drug sleeping tablets is not practical in every case.

How many sleeping tablets are harmful?

The National Institute for Health and Care Excellence (NICE) has published guidance on safe prescribing and stopping medicines that can lead to addiction or withdrawal symptoms in adults. They have concentrated on benzodiazepines and Z drugs which are often used for sleep issues, as well as some medication used for pain relief (opioids, gabapentin and pregabalin). They have also discussed antidepressants which are not addictive but can cause withdrawal symptoms.

Before they prescribe, your doctor will take into account:

• If other methods or medications that are not addictive have been tried.

• Issues that could lead you to becoming addicted to the medication

• That you have all the information you need to make a decision.

What you should know when starting a medication:

• The type of medication and why it has been prescribed for you.

• The starting dose and when doses will be changed if needed.

• The side effects and how long they may last.

• Who to contact if any queries or concerns.

• How long the medication will take to work and how long you will stay on it for.

• How long the prescription given is for - eg, one week, two weeks

• The risks of addiction and overdose.

• When you will have a review.

Your doctor may stop the medication if:

• There is no benefit or it is no longer helping you.

• There are symptoms or signs of addiction.

• Your illness is better.

• There are more harms than benefits to taking the medication.

• You, as a patient, want to stop the medication.

The doctor will stop the medication slowly. They will discuss with you how to do this taking into account issues that may make stopping the medication difficult.

A note on withdrawing from benzodiazepines: if you are on medications such as lorazepam or nitrazepam, you may be switched to diazepam. This medication has a longer half life, meaning it will stay in your body longer reducing any withdrawal effects. Cognitive behavioural therapy (CBT) alongside withdrawing from a benzodiazepine can also help manage symptoms. Your doctor may refer you for CBT whilst stopping this type of medication.

For Further Reading, see below.