Benefits and Drawbacks of Sleeping Pills

By Dr. Gregg D. Jacobs

Sleeping pills used to be the standard treatment for insomnia. Today, they are increasingly recognized as an appropriate treatment for short-term insomnia but not for chronic insomnia due to their side effects and loss of efficacy with continued use. This focus article will explore the use of the most common sleeping pills, benzodiazepines sedative hypnotics (BZDs), and their benefits and drawbacks.

BZDs and Short-Term Insomnia

Americans spend over $400 million on BZDs annually. Examples of BZDs include Ativan, Xanax, Restoril, and Dalmane. BZDs promote sleep by depressing the neural activity of the brain. They are effective for short-term insomnia because they reduce the time required to fall asleep, decrease the number and length of nighttime awakenings, and increase total sleep time compared to a placebo.

They also work by causing amnesia so that we don't remember being awake during the night. Although all BZS are about equally effective, they differ in how long they stay in the body. Those with longer half-lives can stay in the body for more than a day and cause next-day "hangover" effects.

Like most medicines, BZDs can be of value if they are used judiciously. They should only be used as a treatment for short-term insomnia that lasts anywhere from a few days to a few weeks, e.g., if sleep is temporarily disturbed by a stressful event, a medical problem, or jet lag. In these circumstances, BZDs may help prevent short-term insomnia from evolving into chronic insomnia since they can provide needed relief from severe insomnia and break the cycle of insomnia and anxiety.

Some sleep experts also believe that keeping a small supply of BZDs in the medicine cabinet can be helpful for chronic insomniacs because the knowledge that a BZD is available provides a sense of security and minimizes the fear of insomnia. Other experts maintain that short-term use of BZDs may also be appropriate to break the cycle of anxiety and disturbed sleep in severe, chronic insomnia.

BZDs and Chronic Insomnia

Although BZDs should only be used for short-term insomnia, they are often taken on a regular basis for long periods of time- in many cases for years on a nightly basis. Chronic use of BZDs can become very problematic for a number of reasons:

Many people do not have the self-control to use BZDs occasionally and therefore risk becoming dependent upon them psychologically or physiologically. Dependency can result in the belief that one cannot fall asleep without the pill and may also result in withdrawal symptoms that can include anxiety and rebound insomnia. That' why BZDs should always be tapered on a gradual basis.
Sooner or later, BZDs lose their effectiveness if they are used on a nightly or near-nightly basis. This is because the brain receptors that respond to BZDs become less sensitive to their effects, or "down-regulated". In fact, most BZDS lose their efficacy and are no more effective than a placebo in as little as three to four weeks of nightly use. If someone reports that their BZDs give them a good night's sleep despite the fact that they have been taking the pill nightly for years, the effect is likely due to the placebo effect, not the medication.
BZDs suppress deep sleep and dream sleep, resulting in a lighter sleep.
They can produce a hangover effect the next morning that produces greater adverse effects on cognitive functioning than sleep deprivation. This effect is particularly problematic with BZDs that have a long half-life; and, the later the sleeping pill is taken.. Thus, it is a myth that BZDs will improve next-day performance.
There is no evidence that treatment effects persist upon termination of BZDs. This means that, even if they are effective, insomnia will often return when they are stopped.

All of these side effects are more likely to occur the larger the dose, the more frequently taken, and the older you are (as we age, we metabolize medication less effectively, which makes their effects more pronounced).

Newer-generation non-benzodiazepine hypnotics such as Ambien offer multiple advantages over traditional BZDs including consistently documented efficacy, short half-life (2.4 hours) with no active metabolite and rapid onset of action of 30 minutes, and minimal residual effects.

Furthermore, Ambien does not accumulate during repeated administration, causes minimal disruption of sleep architecture, has lowered potential for abuse due to more selective binding properties at GABA receptor subtypes, and is the most commonly prescribed sedative hypnotic.

For these reasons, Ambien is the best choice of a hypnotic for sleep-onset insomnia. If you are taking a sleeping pill other than Ambien, you should talk to your doctor about the advantages of Ambien over your present sleeping pill.

Minimizing sleeping pill side effects
You will minimize the likelihood of side effects and dependence if you follow these guidelines:

Use the smallest possible dose and do not use it for more than two to three weeks at a time.
Use sleeping pills intermittently only after two consecutive bad nights of sleep and never on consecutive nights. This means that you should not use a sleeping pill more than two to three times per week.
Never escalate the dose and use sleeping pills with a short half-life.
Use cognitive-behavioral techniques in conjunction with sleeping pills so that you can taper the use of sleeping pills over time.

A recent randomized trial published in the Journal of the American Medical Association by Dr. Charles Morin and his colleagues directly compared pharmacotherapy to cognitive-behavioral therapy (CBT) in the treatment of insomnia and found that a combined pharmacological and CBT intervention was more effective than either therapy alone over an eight week period.

This suggests that, in the short-term, the most efficacious treatment for insomnia may be pharmacotherapy and CBT in combination, which may enhance treatment efficacy by combining the more rapid improvements of pharmacotherapy with the more durable effects of CBT.

In the long run, Dr. Morin found that cognitive-behavioral therapy alone was the most effective treatment for insomnia. So if you use sleeping pills, use them in combination with non-drug techniques so that you can minimize the use of sleeping pills in the long run.