Sleep Better

Lesson 13: Sleep medicines and when to see a doctor

Goal: know when a sleep problem needs a doctor, and use sleeping tablets, if you ever need them, as a short bridge with a clear way off.

See your doctor if

• you’ve had trouble sleeping 3 or more nights a week for more than 3 months, or it’s affecting your work, mood or relationships
• you snore loudly and someone has noticed you stop breathing, gasp or choke in your sleep, or you wake with headaches or a dry mouth
• you’re sleepy during the day despite enough time in bed, or you’ve nodded off while driving
• you have an uncomfortable urge to move your legs in the evening or at night that eases when you move them (possible restless legs syndrome)
• you suddenly fall asleep during the day, or your muscles go weak when you laugh or feel strong emotions (possible narcolepsy)
• you act out your dreams, shouting, kicking or punching in your sleep
• you get up to pee two or more times a night most nights (Lesson 9)
• your sleep problem comes with low mood, anxiety or thoughts of self-harm

If you’re struggling or feel unsafe, in Australia call Lifeline on 13 11 14, or 000 in an emergency.

Take a sleep diary (Lesson 14) and, if you can, your bed partner: they often know more about your sleep than you do.

Obstructive sleep apnoea

In obstructive sleep apnoea, the throat repeatedly narrows or closes during sleep, so breathing stops or becomes shallow until the brain briefly wakes you to restart it, often many times an hour, without you remembering. It’s common and often missed. Risk is higher if you’re overweight, male or post-menopausal, middle-aged or older, have a thick neck or narrow airway, drink alcohol or smoke. It’s very treatable, and treatment can transform daytime energy.

Sleeping tablets: useful, but plan the way off

Medication can be genuinely helpful to break a cycle: getting through a crisis, a bereavement or a short run of very bad nights so that sleep doesn’t spiral. The key is to treat it as a short bridge back to natural sleep, not the destination.

The risks:

• Common prescription sleeping tablets in Australia include benzodiazepines such as temazepam and related “z-drugs” such as zolpidem and zopiclone. They’re recommended only for short-term use, usually no more than 2 to 4 weeks.
• Tolerance can build within days: the same dose works less well, tempting you to take more.
• Dependence and withdrawal can develop even with fairly short use. Stopping suddenly often causes rebound insomnia, a few nights of worse sleep than before, which convinces people they can’t sleep without the tablet.
• Next-day drowsiness, slower reactions, memory problems and falls (especially in older people). Never combine them with alcohol.

Make a plan with your doctor before you start:

1. Agree how long: a set number of nights or weeks, written down.
2. Use the lowest dose that works. Consider “as needed” rather than every night.
3. Do CBT-I at the same time (Lesson 10). It treats the cause; the tablet only treats the symptom.
4. Agree the off-ramp in advance: how you’ll reduce the dose gradually rather than stopping suddenly.
5. Expect a couple of rougher nights as you come off. That’s rebound, not proof you need the tablet. Stick to the plan.

If you’ve been taking sleeping tablets for a long time, don’t stop suddenly: talk to your doctor about a gradual taper. A 2004 trial in older adults who’d used benzodiazepines for sleep for an average of 19 years found that a supervised taper combined with CBT-I helped most participants come off them successfully.

Over-the-counter sleep aids

• Sedating antihistamines (such as doxylamine or diphenhydramine) are sold as sleep aids. The American Academy of Sleep Medicine advises against diphenhydramine for chronic insomnia because the evidence shows little benefit. They often cause next-day grogginess and aren’t suitable for long-term use or for older adults.
• Herbal remedies such as valerian also showed no clinically meaningful benefit for chronic insomnia in the same review.
• Magnesium, glycine, L-theanine, ashwagandha and other supplements are covered in detail, with their evidence and safety warnings, in Lesson 15.

Melatonin

Melatonin is the body’s darkness hormone. As a medicine it’s mainly useful for body-clock problems such as jet lag and some shift-work and delayed-sleep patterns, rather than general insomnia; the AASM review found little benefit for chronic insomnia in adults.

In Australia, melatonin is a prescription medicine for most people. Adults aged 55 and over can buy a 2 mg prolonged-release product from a pharmacist without a prescription, for short-term use. Products sold overseas or online may contain very different amounts from the label. Ask your doctor or pharmacist before using it, especially for children.

Exercise 13

Read through the “see your doctor” list. If any of it applies to you, book the appointment this week and start a sleep diary to take with you. If you take sleeping tablets, write down how long you’ve been on them and ask your doctor about a plan to come off.

Sources

• healthdirect, Insomnia, Sleep apnoea, Safe use of sleeping pills and Melatonin
• Sleep Health Foundation, Sleeping tablets
• Sateia et al. (2017), Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults, American Academy of Sleep Medicine
• Morin et al. (2004), Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation, American Journal of Psychiatry
• Qaseem et al. (2016), Management of chronic insomnia disorder in adults, American College of Physicians

This course is general information, not medical advice. If you have ongoing sleep problems, loud snoring with pauses or gasping, or sleepiness that affects driving or work, see your doctor. In Australia, if you are struggling or feel unsafe, call Lifeline on 13 11 14.