Medications

When all of the above interventions have failed medications can be considered

There are many medications used to treat insomnia. They range from over the counter to controlled substances.

Sometimes treatment of insomnia starts with medications, but it should not. Medications are not without risk and starting with many of the lifestyle interventions is a better first line option than drugs.

Medications are an easy fix for Americans. It is much easier to pop a pill than take the time and effort to implement lifestyle changes. Twenty-four million prescriptions are written for sleeping pills each year (1).

Advertising executives do not help. Lunesta and Ambien CR spend almost 500 million dollars on direct to consumer advertising a year (1).

Drugs are often taken much longer than they are supposed to be. Most drugs are indicated for short-term use, but many people take them for years on end. This misuse of sleeping aids can lead to many problems including dependency, memory problems sleepwalking, hallucinations and daytime drowsiness.

In addition to approved sleeping pills, there are many drugs indicated for other purposes, used for insomnia. This includes anti-anxiety drugs such as alprazolam (Xanax), antidepressants such as trazodone and pain medications such as Vicodin or Darvocet.

The most common over the counter medication is some form of antihistamine. They often contain diphenhydramine (Benadryl) or doxylamine succinate. Many people do not realize that they are taking an antihistamine to sleep. They assume it is a specific sleeping pill. Popular over the counter products includes Tylenol PM, Sominex, Simply Sleep and Unisom.

Over the counter medications are popular because they are cheap and convenient. The problem is that there are many problems with these medications.

They have not been proven effective in inducing sleep on a consistent basis. For healthy people they are quite effective and safe to use for one to two nights. If used for longer than a couple nights tolerance may develop. Tolerance is when the body gets used to the drug and it is no longer effective.

These drugs are not encouraged for long-term use because they are not proven effective in the long-term, reduce the quality of sleep and are associated with many side effects.

The effectiveness of the sedating anti-depressants has not been shown to be effective in patients who are not depressed. They are not approved for use in sleep, but are often prescribed. Sometimes they are prescribed as agents solely for sleep, but more often they are prescribed to the depressed individual who need help sleeping. Common drugs in this class are included on the table below.

Hypnotics are agents meant to induce sleep. Most of these should not be used if there is a history of drug abuse, untreated sleep apnea, alcohol abuse or pregnancy – particularly the benzodiazepine class. Those who have used these drugs for an extended period of time need to be tapered off slowly and not abruptly discontinued.

Hypnotics include:

• Benzodiazepines
• Nonbenzodiazepines
• Melatonin receptor agonists

The first two classes work on a receptor in the brain called the gamma-aminobutyric acid (GABA) receptor. The benzodiazepines are the older class of drugs and generally have a longer half-life. This means that the drug stays in the system much longer. Sedation often carries over to the next day. The most commonly used benzodiazepine for sleep problems is Temazepam (Restoril). Its half-life is about 9-12 hours.

Benzodiazepines are often used in the treatment of anxiety. Drugs such as alprazolam (Xanax) and lorazepam (Ativan), are indicted for anxiety, but due to their sedating properties are often used for sleep. When used in this way it is an off label use.

Other medications in the benzodiazepines class are older drugs and are not used as often today. They include: flurazepam (Dalmane) and Triazolam (Halcion).

Dependency is a major risk with this class; this is especially problematic in those who use them for more than a few weeks. Withdrawal from these medications can be bad and lead to anxiety, nausea, rebound insomnia, depression, nightmares and memory problems. Gradual reduction in dose is needed when these drugs are used.

The nonbenzodiazepines were more recent additions to the insomnia armamentarium. These medications work differently and do not affect the sleep stages and do not cause REM sleep rebound. This class is associated with fewer side effects than the benzodiazepines.

There are three drugs in this class: Zolpidem (Ambien), Zaleplon (Sonata) and Eszopiclone (Lunesta).

Eszopiclone (Lunesta) works though unknown mechanisms but is thought to interact with the GABA receptor. Its half-life is about 6 hours. It is most effective in higher doses for sleep maintenance and lower doses are more effective in sleep initiation.

Adding medications together has not been shown to be effective. The combination of CBT and benzodiazepines is better than the drug alone.