The use of sleeping medications The use of hypnotic medications (mostly benzodiazepine) in patients with chronic insomnia, either continuously or intermittently, is a subject of controversy. However, the use of “sleep promoting” medications in transient (reactive) insomnia is an accepted and recommended therapy in the short term (three to four days).

It is unfortunate that questionable use of scientific reports by policy makers, and confusion over drug dependence, withdrawal and addiction, have led to misconceptions among the general public and medical practitioners regarding the appropriate use of hypnotic medications.

While there is a group of researchers who believe that no long-term use of hypnotic medication should be allowed many clinicians consider the long-term use of hypnotic medication appropriate in qualified cases and, in the short term, a useful adjunct to other management strategies in chronic insomnia. There is no evidence that benzodiazepines promote self-administrative behaviour except in subjects who use drugs for recreational purposes or who are multiple drug users. The following medications are in clinical use:

benzodiazepines non-benzodiazepine GABA A receptor agonists antidepressants melatonin

Indications for use of hypnotics include: transient situational insomnia

chronic insomnia refractory to other forms of treatment (childhood onset insomnia, some form of psychophysiological insomnia)

chronic insomnia associated with conditions such as restless legs, periodic limb movement disorder or anxiety disorders.

Precautions and contraindications for hypnotics include: patients with a history of recreational drug use, including alcohol abuse pregnancy, particularly in the first trimester, or if breast feeding as benzodiazepines cross the placenta and are excreted in the milk severe obstructive sleep apnoea, because of the increased risk of respiratory depression patients in high risk occupations, such as commercial drivers, heavy machinery operators, workers on call who may need to attend their work in the middle of the night elderly patients because of the increased risk of toxicity.

Choice of hypnotic medication

The choice of medication should consider the clinical situation and the pharmacological properties of the drug used (the pharmacological names are used rather than the brand names). In patients with predominantly sleep onset difficulties, who cannot switch off or have increased anxiety at bedtime, the use of short-acting hypnotics with rapid onset of activity is the recommended choice (triazolam, zolpidem, zoplicone and temazepam). In patients with a tendency to wake up after sleep onset, hypnotics with an intermediate length of action, six to eight, are preferable (oxazepam, lorazepam, temazepam). This group of medications is also useful in people with restless legs and periodic limb movement disorder.

In subjects with anxiety disorders, a long-acting benzodiazepine with a rapid onset of action (diazepam, nitrazepam) may be a better choice, as the prolonged action will be useful the day after to control the anxiety symptoms. The pharmacological characteristics of commonly used hypnotic medications are summarized in the following table: Medication Duration of action Absorption Dose Comments

Temazepam (Normison™, Temaze™)

Intermediate (5-15 hr)

30-60 min

10-30 mg

Zolpidem (Stilnox™)

Short (~2.5 hr)

30-60 min

5-10 mg

Zoplicone (Imovane™)

Short (~ 5.2 hr)

60-90 min

3.25-7.5 mg

Triazolam (Halcion™)

Short (1.5-5 hr)

24 hours) are likely to accumulate over time leading to an risk of side-effects,

Prescribing hypnotic medication It is useful to become familiar with a small number of hypnotics (perhaps two to three) and use them in the context of insomnia management. The choice of individual drugs depends on availability in specific countries. For example, triazolam (Halcion™) is available in Australia but was withdrawn in other countries, including the United Kingdom in the early 1990s, following reports of rebound insomnia, anterograde amnesia and daytime anxiety. Flunitrazepam (Rohypnol™) is also not available in the United Kingdom.

The following principles of prescribing are guidelines for chronic insomnia, although adjustment may be needed in individual patients and specific circumstances: give clear instruction on how to use the medication at the start of treatment, the hypnotic should be used every night for at least two to three weeks to establish a new sleep and wake routine, while other non-pharmacological interventions have the time to make an impact. the use of hypnotic on alternate days is not advisable in the majority of cases, as the “night off” may be troublesome if rebound symptoms are prominent after a few weeks, when a new pattern of sleep is established and behavioural sleep modifications are implemented, gradually reduce the medication close follow-up is necessary at this time.

Timing of administration Patients should take the medication thirty to sixty minutes before bedtime. This has the advantage of achieving an effective blood level and avoids a negative association between going to bed and taking medication, which is particularly detrimental if there is pre-existing bedtime anxiety. Review frequently and be available for counseling. Frequent review often over the telephone, may be necessary until a clear response is achieved so that the dose can be modified or, if necessary, the medication changed.

Important: Always take medications under medical supervision and do not change the dose without consulting with your family doctor. If you are taking other medications interactions between drugs may occur.