How to Stop Taking Pills Without Relapsing into Insomnia

From todoalicante.es

By Doménico Chiappe, Madrid

Patients arrive medicated from primary care when the condition is chronic. Three specialists discuss how they help patients stop taking medication

More than six million people in Spain regularly consume hypnotic sedatives, such as sleeping pills or benzodiazepines. This is especially prevalent among women, increasingly younger, according to data from the Ministry of Health's Survey on Alcohol and Other Drugs. "We live in a country where more sleeping pills are consumed than anywhere else. The problem is that higher doses are needed over time due to tolerance, leading to abuse. In this case, the patient faces two issues: insomnia and abuse," says Carlos Egea, president of the Spanish Federation of Sleep Medicine Societies (Fesmes). "Each year, the proportion of people taking them increases," confirms Ainhoa Álvarez, president of the Spanish Sleep Society. "Most drugs used for insomnia, though not all, are benzodiazepines, which cause dependence and tolerance."

When they reach the specialist, patients with sleep problems are already medicated. "An insomnia patient sleeps poorly or little, struggles to fall asleep, or wakes up and cannot return to sleep, and then feels unwell during the day. A diagnosis must rule out other sleep disorders and confirm insomnia," Álvarez continues. "The issue is that by the time they reach the Sleep Unit, they have often already been through primary care and have been prescribed medication, which is the quickest way to sleep."

The use of these drugs begins before the age of 15 in Spain, with an average age of 46. The groups with the highest consumption have low educational levels and work in unskilled manual jobs, administrative roles, rural areas, social services, or are unemployed, according to the 'Conclusions of the Gender Working Group of the Spanish Council on Drug Addiction and Other Addictions'. "If after an evaluation we diagnose chronic insomnia, the first-line treatment is cognitive-behavioural therapy. If there is no response, it is combined with pharmacological treatment to address the underlying mechanisms and correct the disorder with medication," recommends Adolfo Alcoba, a member of the Sleep Alliance. "The question is what to do if there is already dependence and the patient has been taking medication for a long time and developed tolerance."

"There are two public health issues: general sleep problems and the high consumption of hypnotic sedatives."

The most common drugs for insomnia cause cognitive decline in the elderly, affect memory, create dependence, and require increasingly higher doses until they become ineffective, Alcoba states: "Here are two major public health issues. First, general sleep problems, affecting 40% of the population; and second, the high consumption of benzodiazepines and hypnotic sedatives. We need to reduce this percentage to a minimum. But if someone goes to their GP and says they can't sleep or wake up very tired, they are often given a pill by default. Can they stop taking it later?"

                                                                   A person sitting on their bed at night. (R. C.)

This week, the Sleep Alliance presented the 'Practical Guide to Cognitive Behavioural Therapy for Chronic Insomnia', on psychological intervention in these cases, as the first level of care and to help stop these drugs. This guide outlines several steps: the patient must learn what induces sleep and how to manage these factors, develop a "sleep hygiene routine", control alert stimuli, and apply various measures during insomnia, restrict time in bed, and feel the "pressure of sleep, because if a person doesn't go to sleep and watches TV or uses their phone, they won't sleep and become more alert," says Alcoba, co-author of the study.

"Thoughts about their insomnia problem, which can be intrusive, are changed."

"It has two parts. In the behavioural part, the patient is taught to adopt more suitable behaviours to overcome insomnia, as sometimes we make it worse. For example, staying in bed for too long, hoping to fall asleep. So, we work to change these patient behaviours. In the cognitive part, thoughts about their insomnia problem, which can be intrusive or myths about sleep, are changed," Álvarez explains about a treatment that "is often not offered in the National Health Service. Ideally, this therapy would be provided in primary care."

Years Go By

Something that is not a myth is that insomnia increases with age. "Yes, because we have more problems as we age. Mr. Prostate, Mrs. Hot Flushes, Mr. Pain. Older people have fragmented sleep and not the continuous sleep we all desire. It's more complicated," Egea states. "The age range for sleeping seven to nine hours starts at twenty and goes up to 65, pressured by our working lives. Then comes retirement, which allows more time for sleep, but there are also doctors, anxiety... Each stage has its general problems."

With age, night-time awakenings become more frequent and especially "longer," says Álvarez. "When you're young or a child, you wake up several times at night; it's normal to wake up three or four times. But we turn over, go back to sleep, and don't remember because it lasted thirty seconds or a minute. But when awakenings are longer, we are more aware and have less deep and shorter sleep. Sleep also changes with age. An elderly person may sleep less than two hours at night but take one or two naps, mid-morning and mid-afternoon."

One or Two Naps

Is it beneficial and advisable to take a nap? The experts' answer is 'yes'. "Napping is good, but always short. Less than 30 minutes," Álvarez maintains. "Our brain is programmed to nap, but if it's too long, it will take away from night-time sleep. We tell insomnia patients not to nap for more than 30 minutes, although it depends on each case. Some people work nights, sleep little, and then take a long nap. So, everyone has to adapt their lifestyle."

Egea agrees: "It's only good for about half an hour. The nap complements a little but doesn't replace night-time sleep. It doesn't take away from night-time sleep afterwards, but if you're an insomniac, we don't recommend it."

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