Successful Discontinuation of Regular, Long-Term Use of Sleeping Pills Using Cognitive-Behavioral Therapy and a Gradual, Structured Tapering Program

By Dr. Gregg D. Jacobs

Despite the fact that prescribing guidelines for sedative-hypnotics recommend that their use be restricted to no more than 2-4 weeks, more than 65% of individuals who are prescribed sedative hypnotics use them for more than 1 year, and as many as 30% use them for more than 5 years.

Perhaps the major reason why so many people use sedative-hypnotics long-term is that discontinuation of hypnotics, particularly benzodiazepines, is challenging. Many people get caught in a cycle of long-term use due to physical dependency (e.g., withdrawal symptoms) or psychological dependency (e.g., the belief that one cannot sleep without the pill combined with anxiety about rebound insomnia).

Although cognitive-behavioral therapy (CBT) has been shown to be effective in the treatment of insomnia, few studies have included insomniacs who are long-term users of sedative hypnotics. It is likely that the use of CBT in combination with a structure medication tapering program would enhance the success of discontinuing medication since CBT can prevent rebound insomnia and relapse.

In a study in the February issue of The American Journal of Psychiatry, Dr. Charles Morin and colleagues examined the efficacy of CBT, supervised medication tapering, and a combination of the two approaches for benzodiazepine discontinuation in long-term regular users of sedative hypnotics. The 76 patients in this study were aged 55-82 who complained of insomnia for over 20 years. They used sedative-hypnotics almost nightly for almost 20 years, yet the majority still complained of insomnia (e.g., despite regular use of sleep medication, they still had problems sleeping). On average, patients in this study had made at least a half dozen attempts over 20 years to stop sedative-hypnotic use without success. Thirteen of the 76 subjects were using two or more sedative-hypnotics at one time.

Before and after treatment, patients kept slept diaries and underwent all-night sleep measurements to assess changes in sleep. During treatment, patients were randomized to one of three interventions: medication tapering alone, cognitive-behavioral therapy (CBT) alone, or combined medication tapering plus CBT. The medication taper alone intervention consisted of a gradual reduction in the dose and number of medication nights over a 10 week period (at least a 25% reduction in the initial dose every 2 weeks). Patients receiving CBT alone were taught techniques that included cognitive, sleep restriction, stimulus control, and educational components. The remaining subjects received a combination of sleep medication tapering plus CBT.

69 of the 76 patients completed the study. Across all three groups, the quantity of benzodiazepine (BZD) use decreased by 90% (from 10 mg at pretreatment to 1 mg at post-treatment). Frequency of BZD use across all three groups dropped 80%, from 7 nights per week at pretreatment to less than 2 nights per week at post-treatment. The combined CBT and medication taper group showed the greatest percentage of patients who were medication-free at post-treatment at 85%, followed by 54% in CBT alone and 48% in the medication taper alone group.

Sleep diaries and all-night sleep recordings showed that patients in the combined group and CBT alone experienced the greatest subjective improvement in sleep (e.g., sleep dairies). Sleep recordings revealed that all subjects showed more deep sleep, and less light sleep, as a result of medication tapering.

The results of this study suggest that a combination of a structured sleep medication tapering program and CBT is the most effective approach to reducing and eliminating sedative-hypnotic use. Despite the fact that patients in this study used sleeping pills almost nightly for 20 years, 85% of patients were able to eliminate the medications entirely within an average of 7 weeks. There were no significant withdrawal symptoms in these patients due to the fact that the medication taper was gradual and was combined with CBT, and sleep improved as a result of the medication taper and discontinuation. The reductions in medication were generally well-maintained at long-term follow-up at one year.

Detailed information on implementing a medication tapering program like the one used in this study, in combination with CBT, can be found in my book, Say Good Night To Insomnia.