What makes sleeping pills so addictive?
Sleeping pills, usually benzodiazepines (Temazepam, Valium) or benzodiazepine receptor agonists (Zolpidem, Zopiclone, Stilnox), are so addictive because they do help to lower our physiological and cognitive levels of arousal. Hyper-arousal, especially an overactive mind, is reported by patients with insomnia as one of the major reasons why they can’t get to sleep. Sleeping pills, especially in the first week that you take them, directly target this by quietening the mind and making it easier to drift off to sleep and stay asleep at the start of the night. Unfortunately, our brain adapts to them fairly quickly, so after a week they won’t be quite as effective as they were initially, and they are not recommended for more than 2-4 weeks. This is because people often start to take more of the sleeping pill to try and obtain the same effect that they had initially. This leads to tolerance building up, and also withdrawal effects or rebound insomnia if they are not taken in the same quantity. The patient with insomnia then begins to feel that they cannot sleep without the sleeping pills, and become dependent on them or feel addicted to them.
Telltale sign of sleep aid dependence
People could be considered dependant on sleeping pills when they feel like they can’t go a night or two without sleeping pills. They might think that they will never be able to sleep unless they have a pill and strongly agree that they would rather have a sleeping pill than have a poor night’s sleep. Wanting to increase how much sleeping pills they consume each night or doing so is also a worrying sign that they have become dependent, or if they have rebound insomnia (a really bad sleep) if they have a night without a sleeping pill.
How exactly does one cut back?
Cutting back is best done with the assistance of a medical doctor, ideally a sleep physician or psychiatrist with experience in treating sleep disorders. A behavioural sleep medicine practitioner or a general practitioner with knowledge of cognitive behavioural therapy for insomnia (CBT-I) could also help. The process is about cutting back how much you are consuming gradually alongside learning cognitive and behavioural strategies for how to improve your sleep without taking medication. By learning non-drug strategies to increase your sleep pressure, align your internal body clock to the time you want to sleep, and lower your arousal levels, people can become good long-term sleepers and no longer have the need to take sleeping pills to help them sleep.
How long does it take for your sleep to get back on track?
Cognitive behavioural therapy for insomnia (CBT-I) can improve sleep quite quickly. My clinical trial found that only 4 sessions of therapy across 8 weeks (one session every two weeks) was enough to significantly improve people’s mood and sleep. Coming off sleeping pills should be done slowly and with the assistance of a qualified medical practitioner, but could be achieved within 4-8 weeks too, depending on how severe the problem is. It is not recommended to stop immediately if you are currently taking large doses, but to seek medical advice and cut down slowly to reduce the risk of seizures.
What bedtime routines really work for people with Chronic Insomnia?
For most patients that I see with chronic insomnia, I recommend they stop having caffeine 9 hours before sleep, minimise how much alcohol they consume (especially important if they are also taking sleeping pills as consuming both can be dangerous and cause respiratory problems), stop exercising 3 hours pre sleep, try to have dinner at least a few hours before bedtime, turn off all bright screens two hours before bedtime and do something relaxing for the last 30-60 minutes before bed. Once they feel sleepy, as long as it is around their usual bedtime, they can go to bed. In bed, the aim is to not try to force yourself to sleep, but to keep your focus on something distracting or relaxing and to allow sleep to come. If sleep doesn’t feel close within 20-30 minutes, they should sit up or get up, do something relaxing that can help calm themselves down, and then return to bed or lie down again once they feel sleepy. If they then keep a fairly regular sleep schedule and spend no more than 8 hours in bed each day they should be sleeping fairly well within 2-4 weeks. If they do not do this, seeking help from a behavioural sleep medicine specialist or a psychologist who practices CBT-I could help by teaching the patient mindfulness, relaxation and cognitive strategies to reduce their arousal and improve their sleep. Morning sunlight for 20 minutes, a bit of exercise during the day, meditating for even ten minutes a day, keeping naps to under 30 minutes and writing down plans to address your worries during the day can also really help.
Some examples of successful recovery stories from your patients
Our clinical trial had many participants who were on antidepressants and were still feeling depressed and sleeping poorly. We thought that one of the main reasons why they were still feeling depressed was their insomnia, which many participants had been experiencing for more than ten years. By improving their sleep across four sessions of CBT-I, they started to feel much better, happier, less stressed, less anxious and less fatigued. It made a massive difference to the quality of life for many of these participants, and the improvements made through CBT-I are usually long lasting, in comparison to sleeping pills, which only work for a small period of time and result in sleep problems coming back once you stop taking them.
What are some little known tips and tricks to get into a normal sleep routine
Probably the least well known trick that is the most supported by scientific research is to spend less time in bed if you aren’t sleeping well. Most people with insomnia tend to spend more time in bed if they aren’t sleeping well, but this only increases their time spent worrying in bed and time awake in bed each night. Set a standard wake time each day, even on the weekends (say 6:30am), then determine how much sleep you could realistically get on a nightly basis (say 7 hours), then add 30 minutes to this for your time in bed prescription for the next two weeks. This means that you should go to bed at around 11pm each night (as long as you feel sleepy – if not, stay up later), and get out of bed at 6:30am every morning no matter how badly you slept the night before. You will feel more tired during the day initially, but this will increase your sleep pressure, making it easier to fall asleep quickly by 11pm the next night. As long as you don’t begin to worry more and more about not sleeping enough, you should start falling asleep a lot quicker and remaining asleep for longer each night. It should also help you to get back to sleep more quickly if you wake up during the night. If this doesn’t work after two weeks, seek professional help.
How does one deal with the fear of not being able to fall asleep?
Remind yourself that sleep is an involuntary process, just like breathing. Our brain and body need it, and will try to help us to obtain enough. The important thing is to try not to worry too much about it, and don’t try to will yourself or force yourself to sleep. This only increases our stress or arousal levels, which can make it tough to get to sleep. So if you are afraid of not being able to fall asleep, try to reassure yourself that you can as long as you don’t get in the way, Then accept that you are not asleep yet, and do something distracting or relaxing. Practice deep breathing, progressive muscle relaxation, imagery or visualisation, meditation, or listen to relaxing music, white noise, nature sounds, an audiobook or even the radio (ideally with a sleep timer on it). I’ve even listened to stand-up comedy before. The app calm has a lot of great features, and is worth downloading if you want to try some different relaxation or distraction techniques. Then allow sleep to come.
What’s the mindset of a normal sleeper versus an insomnia?
A “normal” or good sleeper knows that they will occasionally have a poor night of sleep, especially if they are a little stressed, and that is okay. They don’t try to get a certain amount of sleep each night and aren’t too rigid about their routine either. They don’t worry that a bad night of sleep will wreck their health or their performance at work or wreck their sleep for the rest of the week either. Ask a good sleeper what they do to sleep well and they will respond “nothing”. People with insomnia often put too much emphasis on their sleep and the consequences of not getting enough. They feel that they need to do everything perfectly in order to get a good night’s sleep, and really stress out if they cannot control their environment or if things don’t go according to plan. By becoming more accepting of things as they are, more flexible in their routine, less concerned about not sleeping enough and more focused on the other things in their life, someone with insomnia can develop the mindset of a good sleeper over time.
What is YOUR sleep routine?
My sleep routine at the moment is to go to bed at around 10pm as long as I am feeling sleepy and wake up around 6am every morning. I try to get some morning sunlight and exercise each day, meditate for 10 minutes a day and stay off my phone after 8pm. I also write down a plan for any concerns that are playing on my mind. That’s it.