insomniaSleep Medication

Why medications rarely solve insomnia.

By July 8, 2019 August 19th, 2019 No Comments

And how they can make insomnia worse.

People often ask me for advice when it comes to medications for insomnia. Is Trazodone better than Mirtazapine? Should they combine Ambien with Melatonin CR to avoid early morning awakenings? A lot of people with difficulties sleeping feel as if they’ve not yet found the right medication to treat their insomnia.

There is no doubt that some medications can make you fall asleep faster and make you sleep more soundly. However, you have to consider at least two things:

1. For how long are sleep aids helpful?

and

2. Why/how are they making me sleep better?

Some of the concerns with sleep medications is that they are sedating. Virtually all medications used for sleep make you drowsy to some extent. That’s kind of the point. For most people this is not a big problem but if you have any type of balance issues it could be. Medications such as Ambien cause many elderly to fall which is not a benign event. If a 75 year old person has hip fracture that means they need surgery which means they will be immobile. They may develop a DVT and have a pulmonary emoblism and even die just because they took a sleep aid. All this being said for most people increased fall risk is not a major concern.

Daytime drowsiness, often described as a “hangover effect” is a concern and many stop taking sleep aids because of this. Again I don’t think this is a major concern if it outweighed the benefits.

Dependence is a concern for many providers as well as patients. I definitely understand people who do not want to get hooked on drugs for sleep. However, you could make the case that as long as you are sleeping better and have access to a medication that helps you could accept this dependence. Many people are dependent on a stimulant: caffeine, and seem to not only accept but embrace this dependence. I do feel that this is a concern but again just like drowsiness dependence may be acceptable if benefit outweighs the risks.

So what is the major concern?

Tolerance.

When I tell patients that tolerance is a big concern many confuse it with dependence. Dependence when it comes to sleep aids would be inability to fall asleep without a medication, becoming dependent on them. Tolerance on the other hand is when gradually a medication stops working. Becoming “immune” is another way this is often described. Now is that so bad? Yes it is, because now you are in a position where you sleep no better but you are taking a sleeping pill. Let me share a very common scenario with you:

Someone has a hard time sleeping and is prescribed a sleep Ambien 5 mg. It works great. But 2 months later the patient is having recurrence of insomnia again and the dose is increased to 10 mg. Now her or she is sleeping well again. 2 months later 10 mg is not enough. Fast forward a year and this person is taking Ambien 12.5 mg extended relase, 5 mg Melatonin and 25 mg Trazodone and is still having insomnia.

Well now you have a problem. You don’t want to take sleeping pills in ther first place. You certainly don’t want to take a medication that is not helping. But when you try not taking your sleep meds you don’t sleep at all. Tolerance has put you in this rough spot.

I do see a fair number of people that have taken a sleep aid for many years and it seems still to be working. I don’t know to what extent the medication still is effective and to what extent it is a placebo effect. I tried searching pubmed just now but did not find any studies on tolerance with common sleep aids but according to “Say go0dnight to insomnia” tolerance is developed to all sleep aids after about 6 weeks and all effect after 6 weeks is placebo effect.

Hopefully one day everyone with insomnia will at least have had a chance to try CBTi before taking any type of sleep aid.

Please as always share your thoughts and if you know someone that has difficulties sleeping: tell them about CBTi!