Sleeping Drugs

Sleeping Drugs

Sleep

        Sleep requirements vary from person to person and so 'normal' sleep is what suits you under ordinary everyday circumstances. The amount of sleep you need is much a part of you as your appetite or your conscience. If your sleep is disturbed for only a night or two, this is usually of no consequences but, if the disturbance persists for two or more weeks, then you have a sleep problem and need to take action.

        Insomnia really means sleeplessness but, nowadays it is used to describe most sleeping difficulties. These include difficulty in getting off to sleep, inability to stay asleep, frequent awakenings, restless sleep - often with night-mares, early morning wakening, and sleep which is not refreshing (you wake up and continue to feel as exhausted as you did when you went to bed).

        There are many causes of sleep disturbance - these may be social, physical or mental. Among social causes are changes in your environment such as a strange bed or bedroom, changes in temperature, noise, motion, and changes of routine like going on night work. Pain from any cause, irritation of the skin, discomfort from indigestion and muscle cramps are some of the physical causes of disturbed sleep. Emotional disorders are a common cause of persistent insomnia. However, remember that social, physical and mental factors are all interrelated. Problems at work may produce anxiety which may produce insomnia. Persistent noise at night may interfere with sleep which may cause you to worry about lack of sleep, which may then produce tension and irritability resulting in further difficulty in sleeping. The death of a close friend or relative, the loss of a job, failure at work, or in an examination may trigger on psychological symptoms, a prominent one of which may be disturb sleep. 

     

        Insomnia must be always regarded as a symptoms of some underling disorder. This is of particular importance in psychological disorders, especially in those patient who feel anxious, tense and/or miserable. In such patients insomnia may be only one of a group of mental or physical symptoms which the may experience. It is therefore, wrong for doctors to prescribe sleeping drugs as the only form of treatment in these patients.

        Drugs may even cause insomnia. For example, caffeine in tea and coffee may keep you awake, Particularly as you get older. Regular alcohol drinkers may find themselves waking early and people who take heroin or morphine may find their sleep impaired. Amphetamines, most slimming drugs, and some antidepressant drugs may keep you awake. So may  some drugs used to treat nasal catarh, colds and asthma.

we really know very little about sleep and its function. It is related to various anatomical structures in the brain and to certain chemical changes. It produces electrical changes in the brain, eyes, and muscles. These can be measured by electrical tracings of muscles ( electromyograph, EMG), eye movements ( electro-oculograph, EOG) and brain waves (electroencephalagraph, EEG). From these tests two main kinds or 'normal' sleep activity have been defined: a stage of non-rapid eye movements(NREM sleep) which is followed by a stage rapid eye movements (REM sleep). NREM sleep is called orthodox sleep and is the stage we 'think': REM sleep is called Paradoxical sleep and is the stage when we 'dream'. It seems that both stages are essential for health. 

Breaking the Sleeping - drug Habit

       Tests have shown that sleeping drugs disrupt normal sleeping patterns. All sleeping drugs suppress paradoxical sleep but when these drugs are stopped paradoxical sleep increases. As paradoxical sleep is associated with dreaming, withdrawal of sleeping drugs (even after few nights) may results in restless sleep with dreaming and nightmares. These withdrawal effects make the individual think that he is unable to sleep without sleeping drugs, not realising that the drug's effects have produced the disturbed sleep.

     If you have been taking sleeping drugs nightly for weeks, months or years and wish to stop them you must reduce the dose very slowly over many weeks and therefore it is better to consult your doctor, who will be able to give you a small- dose preparation to help you do this. A gradual reduction in dosage may enable you to break a long-lasting sleeping-drug habit. Even so, you are bound to have restless nights until your brain gets used to sleep without drugs. This may take several months.

Sleeping Drugs

   These drugs depress brain function: in small doses they are used as sedatives (to calm you down) and in larger doses as hypnotics ( to send you to sleep). 

   Sleeping drugs are drugs of dependence and you can become dependent upon them. The restless sleep which results when you stop these drugs may strengthen your belief that you need to go on taking them, but you should realise that you disturbed sleep is caused by withdrawal symptoms due to physical dependence on the drugs.

   Physical dependence will cause insomnia and withdrawal symptoms when a sleeping drug is stopped suddenly. These include anxiety, trembling, weakness and dizziness. tolerance may develop to sleeping drugs within 3 - 14 days of starting them. This means that you will get less effect from the same dose over time and therefore there is always the danger that you may increase the dose in order to obtain the same effects. With some of these drugs there may also be an increased breakdown in the liver. Producing a decreased sleeping time and an increase in the average dose required to maintain sleep so that you start to wake earlier. Nevertheless, it is surprising how many patients stay on these drugs for years and years without increasing the dose. Even so, tolerance is a danger and if you find yourself having to increase the dose of your seeping drug to get same effect then consult you doctor. you are in danger of becoming addicted.

   If you drink alcohol regularly you ought not to take these drugs regularly. This is because alcohol is also a depressant of the brain and tolerance may develop to alcohol. It is quite easy to take an overdose of either and the combination may be fatal. Do not forget, therefore, that although you may be able to tolerate an increased dose of alcohol or sleeping drug the lethal dose of these drugs remains unaltered so that their combination can rapidly prove fatal. Another important point to remember is that sleeping drugs increased dose will actually make you anxious, irritable and depressed in the daytime. An increased dose will actually make you worse. This also applies taking more alcohol and/or sleeping drugs, it is the drugs that are having this effects.Not a few people have become trapped on this downward course which may end in suicide.

    Like alcohol, sleeping drugs cause intoxication if taken in a dosage above that normally recommended. Further, elderly and debilitated patients and patients with impaired heart, kidney or liver function may develop intoxication at 'normal' dosage. Signs of intoxication are similar to those of alcohol - confusion. difficulty in speaking, unsteadiness on the feet, poor memory, faulty judgement, irritability, over-emotion, hostility, suspiciousness and suicidal tendencies.

    The deliberate taking of an overdose with suicidal intent accounts for most cases of overdoses, but accidentally self-administered overdose may occur. If you take a dose of sleeping drug and fail asleep  you may reach out and take another dose. The effects of this increased dose may make you confused and you may take further doses without knowing ( or remembering subsequently). Therefore, never keep sleeping drugs by your bedside, keep them locked in a drug cupboard. Only take the recommended dose and leave the bottle in the locked cupboard. If you are responsible for, or live with someone who is elderly, debilitated or depressed, and on sleeping drugs, then supervise their administration.

  Do not forget that if you are tense or miserable, alcohol and sleeping drugs, although helping you at first, may eventually make you feel worse. You may sleep all right and awake feeling less tense. only to become tired, irritable and bad-tempered later in the day. One more important point to remember about these drugs (especially alcohol) is that they may reduce the effects of antidepressant drugs.

  Sleeping drugs impair learned behaviour and interfere with your power to concentrate, therefore watch your driving. They may increase pain perception and if given along with pain-relievers they are useful but if taken alone they may cause restlessness and confusion in many vital organs, particularly nerves, muscles, respiration, and the heart and circulation. They may produce any state from mild sedation to confusion and unconsciousness. Like alcohol they may produce different effects according to the situation in which they are taken. At a discotheque they may produce  and excitement, while if taken on retiring to bed they may produce sleep. The combination of a strange environment (e.g. Admission to a hospital ward) and a dose of sleeping drugs may make  elderly patients very confused and disoriented. This is warning against the habit of giving patients sleeping drugs as a routine just because they are in hospital: Although very convenient for the night staff it is often not necessary and may lead to the development of the sleeping-drug habit when patient eturns home. Also, there is some evidence that drug-induced sleep may interfere with normal restorative functions of sleep. Seeping drugs must be used with special caution in patients with chest and heart disorders.

    Do not forget that sleep produces by drugs is not natural
It may be appropriate to take sleeping drugs for a night or two during periods of stress ( e.g. after a bereavement ) or after periods of intense work when you just cannot relax, or intermittently though long periods of stress or when travelling over night o working shifts. In such circumstances they should only be taken for a few nights on a row, because it is accepted that sleeping-drug habit is a real risk after several nights of drug- induced sleep. If you have a persistent sleep then you ought to consult your doctor. But, of-cause, he does little good if he gives a quick consultation and a prescription for sleeping drugs with instructions to get more from his receptionist when you need them. Do not forget that emotional problems are a common cause of insomnia: for example, frequent headaches, feeling anxious or tense, sad, depressed or tearful, backaches, pains in the chest, indigestion, dizziness, no energy, feeling fed up, feeling irritable, fears about your health or going out by yourself, loss of appetite, loss of interest in sex, loss of weight, palpitation, feeling of guilt, feeling not wanted or feeling that other people are talking about you. These are only some of the group of symptoms which should help your doctor diagnose a psychological disorder and organise appropriate treatment.

   If you have a psychological disorder, the use of sleeping-drugs may aggravate your condition, especially if you are feeling sad or miserable. It is important to recognise what are lablled as 'depressive symptoms. This include characteristic sleep distrubances, and antidepressant drugs may be effective in relieving them. This again highights the importance of the initial treatment of insomnia. You and your doctor need to consider together as many as possible of the factors which may be causing you insomnia.

   What about those patients who have developed the habit of taking sleeping drugs every night? They are often elderly and many of them live alone ore in residential homes. I think it would be wrong to give them guilt feelings about being on drugs but it may be advisable to wean them gradually off sleeping being on drugs but it may be advisable to wean them gradually off sleeping drugs, particularly if they are depressed, anxious or tense, drink alcohol regularly, show signs of intoxication or have impaired kidney, heart or liver function.

  In the treatment of insomnia there are many alternatives to sleeping drugs, such as a hot bath before retiring, reading a book, taking a walk, not having too large evening meal, cutting down on coffee, tea or cocoa in the evening, reducing smoking, reducing alcohol intake, trying to get some regular exercise and fresh air during the day and probably most important of all being taught how to relax. The ritual just before going to bed may condition you to go to sleep-undressing, washing, etc. A milk-cereal drink may help you sleep get off to sleep and, of course patients with pain, discomfort and irritation of the skin need more specific treatment, as do those with other physical or psychological symptoms.


Sleeping Drugs

Benzodiazepines 

  * Fluintrazepam ( Rohypnol)
  * Flurazepam ( Dlmane) 
** Lorazolam ( Dormonoct)
** Lormetazepam
  * nitrazepam ( Mogaon, Remnos, Somnite, Unisomnia)
** temazepam

  * Long-acting ( 6- 10 hours)
** Short- acting ( up to 6 hours)

The Benzodiazepins have four main uses - to produce sleep, to relieve anxiety, to relax skeletal muscles and to treat epilepsy.

  Common adverse effects produced by Benzodiazepines include drowsiness, light-headedness, and loss of control over voluntary movements (ataxia). They should be used in the smallest possible effective dose for the shortest possible duration of time. 

Warnings

  Benzodiazepines should be used with the utmost caution in pregnancy. The use of high doses during labour or prolonged use of daily doses in the last three months of pregnancy may depress breathing and cause floppy limbs and poor sucking in new-born babies for a few days, and occasionally withdrawal symptoms. 

   They should not be taken regularly by breast-feeding mothers because they may  produce lethargy and weight loss in the baby, and they should not be used in patients with severe phobias or obsessional illness o to treat depression or serious mental illness. ( e.g. schizophrenia). 

   The dose of benzodiazepines should be reduced in patients with long-standing kidney or liver disease and in patients with severe, long-standing chest diseases such as chronic bronchitis and emphysema.

   They can reduce ability to carry out skilled tasks so that they can affect ability to drive motor vehicles and operate moving machinery. They can increase the effects of alcohol.

   Benzodiazepines should be used with great caution in elderly patients because of the risks, particularly of confusion, ataxia and incontinence of urine. Elderly patients should be given no more than half the normal recommended daily dose for adults.

  These drugs can produce opposite effects ( paradoxical effects ) in some people. Instead of acting as 'downers', they act as 'uppers', and the patients become excited, aggressive and confused. Underlying depression may be triggered off and the patient might become suicidal. 

   They can increase the effects of other drugs which depress brain function ( e.g. sleeping drugs, antidepressants, pain- relievers and anaesthetics). These can increase the risks of using some anti-convulsant drugs, e.g. hydantoins and barbiturates.

Addiction to Benzodiazepines

   The Benzodiazepines are 'downers', they calm you down and send you to sleep. They cause tolerance, cross-dependence with other depressants of the brain ( e.g. sleeping drugs, alcohol ) and they can cause addiction.

Benzodiazepines withdrawal symptoms 

   A substantial number of individuals who have taken a benzodiazepine regularly everyday for more than two to three weeks will experience some withdrawal effects if they stop the drug abruptly. particularly if they have been using higher than average doses. they may experience a few or many of the following symptoms: increased anxiety, tension and panic, depression and feelings of suicide, irritability and outbursts of rage, over-activity and poor headaches, nausea and loss of appetite, a metallic taste in the mouth, palpitations, trembling, faintness, dizziness and sweating, flu-like symptoms, tight and shoulders. They may become aware of sensations in their body, for example, creeping sensations in the skin, and they may become very sensitive to light, noise, touch and smell. They  may get strange feelings of movement, feel depersonalized ad if they are not themselves, feel unreal as if they are in a dream and develop a fear of going out.Their arms and legs may feel heavy and wobbly and they may develop pins and needles in them.
    These symptoms may occur 2-3 days after stopping an itermediateacting benzodiazepines, within a few  hours of stopping a short- acting and with long- acting ones withdrawal symptoms may occur about 7-21 days after stopping the drug. Symptoms usually last from 1-3 weeks, but may go on for months. 

Rebound Anxiety on stopping Benzodiazepines

   Rebound anxiety may be a serious problem after stopping benzodiazepines. The individual may develop panic attacks which are so severe that he or she may become housebound and never want to go out for fear of developing an attack. during an attack, breathing may become rapid, the heart may beat quickly, and there may be light-headedness and dizziness. Sweating and trembling may occur and the legs may like go jelly. A feeling of complete panic may develop, as if something totally catastrophic is going to happen. These attacks only last for a few seconds and nothing does happen, but the individual is left feeling totally exhausted. Many of these symptoms may be caused by rapid breathing and there is no doubt that controlled breathing ( From the abdomen) may stop most of them from developing.    

How to withdraw Benzodiazepines?

   If you have been taking Benzodiazepines regularly every day for weeks, months or years and wish to stop the drug with a minimum withdrawal symptoms, it is important to reduce the daily dose of your dug slowly (e.g. every two weeks) and to be prepared to experience a few or many symptoms varying degrees of intensity. It may take you weeks, months or even a year to be able to stop your drug completely without developing unpleasant symptoms. If you are on an intermediate- acting benzodiazepine it is important that you switch to a long-acting one such as diazepam and take the full dose at bedtime.

  In addition to switching to diazepam and then reducing the daily dose by 2.0 to 2.5 mg every two weeks, you will need advice and counselling from you doctor or other health-care worker, particularly a clinical psychologist. You may also find it useful to attend a self-helping group.

  If withdrawal symptoms occur maintain the dose until symptoms improve and then start to reduce again but more slowly. Remember the time needed to withdraw from benzodiazepines may take anything from 4 weeks to over a year. Beta-blockers should only be tried if other measures fail. Avoid anti-psychotic drugs because these may worsen benzodiazepine withdrawal symptoms. Only use antidepressants if clinically depressed. Equivalent doses of benzodiazepines are diazepam (5mg) , Chlorodiazepoxide(15mg), loprazolam (0.5 - 1.0 mg), oxazepam (0.5 mg), and temazepam ( 10 mg).

   Benzodiazepines should be used only for the short-term (2-4 weeks) relief of anxiety that is interfering with an individual's ability to cope with the everyday stresses and strains of living. Do not use to relieve mild anxiety.


Other sleeping drugs

Chloral betaine ( Welldorm tablets)
Chloral hydrate (chloral, Noctec, Weldrom elixir)
Chlormethiazole ( Heminevrin)
triclofos sodium ( triclofos)
zolpidem (Stilnoct) 
zopiclone (Zimovane) 

Sedative antihistamines

diphenhydramine ( Medinex, Nytol)
promethazine ( Phenergan, Sominex)

Barbiturates 

amylobarbitone ( Amytal)
amylobarbitone sodium ( Sodium Amytal) with quinalbarbitone ( Tuinal)
Butobarbitone ( Soneryl)
quinalbarbitone sodium ( Seconal sodium) 

  


Source: Medicines by Peter Parish.