SLEEPING TABLETS

The use of sleeping tablets is a controversial issue. We are often told that sleep is a vital process and essential for our health - so why not use sleeping tablets to achieve this?

If a perfect sleeping tablet could be made, it would be effective at getting you to sleep straight away and would lead to perfect, deep and restorative sleep. It would be safe, reliable and without any side effects. 

Unfortunately, such a sleeping tablet does not exist. The ones that we do have a mix of pros and cons, and so whether we prescribe these is based on weighing the factors up.

On one hand, sleeping tablets can be a relatively quick way to get yourself to sleep better if your routine has been disrupted. 

On the other hand, they often have side effects, they can lose their effectiveness quite quickly over short periods of time, and ultimately, they don’t deal with the root cause of why you aren’t sleeping well. For this reason, sleeping tablets are sometimes prescribed for short-term insomnia, but are not considered an effective treatment for long-term insomnia.

WHAT ARE THE TYPES OF SLEEPING TABLETS?

Sleep is a complex process, using many different systems in the brain. For this reason, there are many different types of sleeping tablets available. 

Some work on very specific systems in the brain and so often have fewer side effects. Others cause a more global type of brain sedation, which usually causes more side effects. 

Key side effects which are common amongst these medications include the hangover effect – where the sedating effect persists into the following day making it difficult to concentrate or remember things. Loss of balance may occur, which is extremely important in some older patients who may already have poor balance for other reasons. This is also a concern if you often have to get up in the night to pee as you could trip in the dark. This sedation can also lead to the worsening of other sleep disorders such as snoring or obstructive sleep apnea. We will run through the different drug types here.

ZOPICLONE

Zopiclone is one of the commonest sleeping tablets prescribed in the UK. It belongs to a family of medicines called Non-Benzodiazepine Receptor Agonists (this is a bit of a mouthful, so they are often helpfully referred to as Z-drugs). These are currently licensed in the UK for short-term prescriptions for insomnia.

On the plus side these medicines work quickly, and are also rapidly broken down by the body – known as a short half life. This means there is usually less of a hangover effect in the morning.

On the negative side – there is still a hangover effect in the morning! This is very important if you, for example, commute to work by car. Studies have shown that there are significantly increased car accidents the morning after having taken these drugs. Also, most studies into this use healthy volunteers. If you are elderly, or have other illnesses, the sedating effect is likely to last much longer. These medications can also be addictive, and if used for long periods can lead to withdrawal effects

BENZODIAZEPINES

These were some of the original sleeping tablets. They are globally sedating and so can be effective for getting to sleep, but often with a lot of sedation-related side effects, including exacerbating obstructive sleep apnea. 

There are a number of different types of benzodiazepine, some quicker acting and so helping with sleep-onset insomnia, others longer-acting to help reduce wakenings overnight. They include temazepam, clonazepam and diazepam.

People get used to these medicines quite quickly, and so need higher and higher doses. There is also a significantly higher risk of addiction if used long-term. For this reason, they are much less commonly prescribed in the UK, with most doctors preferring to prescribe Z-drugs.

ALCOHOL

Alcohol is often referred to as the world's most common sleeping medicine. Alcohol affects many body processes and, unsurprisingly, has effects on sleep. 

Alcohol can make you feel relaxed and sleepy so you fall asleep faster, but can lead to disrupted sleep later on in the night. Excess consumption has a negative effect on sleep, with research suggesting that even moderate amounts of alcohol can reduce sleep quality by nearly 25%.

This disruption can be because of developing a headache during the night, causing hot flushes, or even just needing to get up for a pee. However, it is also known to disrupt the balance between the sleep stages, particularly during the later stages of sleep, and this results in poorer sleep quality. This effect is worsened in people with insomnia and sleep-disordered breathing.

Good sleep is about more than just how quickly you fall asleep.

ANTIDEPRESSANTS

Antidepressants can help sleep in two main ways. The first reason relates to the relationship between sleep and mental health. Depression and anxiety are known to disrupt sleep. Depression often causes early morning waking, and anxiety can make falling asleep a particular challenge. Having effective treatment of these conditions can have a positive knock-on effect on your sleep.

The second way is as a side effect of the medications themselves. Particularly the older antidepressants such as amitriptyline, mirtazapine and trazodone, have sedating side effects, which can be beneficial in insomnia. 

However, their effect is quite varied and sometimes unreliable. Sleep can sometimes actually be disrupted by these medications, particularly at the start of treatment.

ANTIHISTAMINES

These medications are often available over the counter. Histamine is often known to be part of the body’s response to allergic reactions, but the chemical itself works in a number of parts of the body, including in the brain where it is involved in the pathways that coordinate sleep. 

The older antihistamines often make you drowsy. While this can sometimes help with sleep, the evidence for this in insomnia is unfortunately lacking. These medications also often work for a long time and can lead to significant daytime sleepiness as well.

MELATONIN

This has become very popular in recent years. It is a naturally occurring hormone, which has an appeal to patients struggling with their sleep who would prefer more naturally-occurring treatments. It is available over the counter in some countries, but in the UK it is only licenced on prescription for certain scenarios, including being over 55 with insomnia, and for children with neurodivergent disorders such as autistic spectrum disorder or ADHD.

When used to help sleep, large studies have demonstrated that melatonin is unfortunatly not very effective at inducing sleep or reducing wake episodes during the night. It is however, a much safer medication than some of the older sleeping tablets.

NEW HORIZONS

Whereas some sleeping tablets cause global brain sedation and with it usually a greater number of side effects, other medications work on much more specific pathways in the brain.

A new sleep pathway in the brain has recently been explored that involves a chemical called orexin. Orexin is a wake promoting brain chemical that keeps us alert, and therefore reducing the activity of orexin, through an orexin-blocker, helps make us sleepy. 

This new family of drugs is known as the Dual-Orexin Receptor Antagonists (DORAs). Large trials have been very encouraging, demonstrating these medications to be safe, improve sleep quality, reduce wake episodes at night and have no rebound symptoms on stopping the medication. NICE, (the National Institute of Clinical Excellence) is in the process of setting up treatment with a DORA and this is likely to be available on prescription in the UK soon.