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August 2008 – Volume 4, No. 4
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Poor sleep has many Canadians
turning to snoozing aidsFinding the right dose for the right person can be tricky amid glut of prescription and over-the-counter optionsby Jadranka Bacic
With as many as 3.3 million Canadians affected by a sleep disorder, according to Statistics Canada’s Community Health Survey, more people are turning to sleeping aids to catch their forty winks.
Five of the 10 most commonly dispensed prescriptions in psychiatry, including lorazepam and clonazepam, are medications often used to treat sleep problems, reports IMS Health Canada. This doesn’t include over-the-counter products currently flooding drugstore shelves.
Wende Wood, a drug information and drug use evaluation pharmacist at the Centre for Addiction and Mental Health, says there really aren’t that many medications intended purely for the purpose of getting a person to fall asleep.
Prescriptions for heavily sedating barbiturates have steadily declined since the 1970s because the amount between a therapeutic dose and an overdose is dangerously close, says Dr. Wood.
There are now other options, including benzodiazepines which are prescribed for both sleep and anxiety, hypnotics like zopiclone and zolpidem which are specifically indicated for sleep, and antidepressants like trazodone and chlomipramine.
There are also many over-the-counter medications marketed as sleep aids, such as Unisom and Nytol, but in reality these simply exploit the side effect properties of diphenhydramine that produce drowsiness.
Diphenhydramine is more commonly known as Benadryl.
“Most sleep problems are a sign of another underlying disorder like depression, pain, mania or anxiety," says the psychiatric pharmacist. “It’s so important to conduct a thorough evaluation if a patient is complaining of sleep problems to make sure you prescribe the right medication for the right length of time, and at the optimal dose."
Sleep disorders, including sleep apnea, excessive daytime sleepiness, narcolepsy and insomnia, have been linked to numerous health risks and medical illness, including increased risk for injury, depression, anxiety and heart disease.
Dr. Wood has been specializing in psychiatric drugs since becoming a pharmacist 15 years ago.
“There is still a lot of art behind the science of psychiatry," she says. “There is more nuance around prescribing medication and much more patient interaction."
The potential for confusion and misunderstanding between physicians, pharmacists and patients can be high when it comes to sleeping aids.
It is common for some physicians to prescribe a sleeping pill for some immediate relief before treating the underlying condition, but Dr. Wood warns they should only be dispensed for short-term symptomatic use.
A two-week supply should be long enough to help establish a sleep pattern. This can be extended to four to six weeks in cases where the person would benefit from some immediate relief before other medications kick in to treat an underlying psychiatric disorder.
A lot of the confusion for patients comes from pharmacy printouts.
“They pick up their prescription for trazodone and read that trazodone is an antidepressant, but wait, they had only complained to their physician of having trouble sleeping, not feeling depressed," explains Dr. Wood. “It is important for psychiatrists to explain to patients why they are being prescribed certain medications and exactly what symptoms they will help."
Many medications are adapted to induce sleep. A 300 mg dose of trazodone is typical for depression, but it becomes a sleep aid when the dosage is adjusted to 25 to 50 mg.
Dr. Wood is now seeing the antipsychotic quetiapine prescribed for sleep in lighter doses of 50 to 100 mg. Her feelings are mixed when it comes to this medication’s modification.
“Quetiapine has a very strong anti-histamine effect so some people question whether at those low doses it does anything more than your basic Benadryl," she says. “There are however some advantages to choosing this drug over a benzodiazepine because it is less likely for some patients to develop a tolerance or dependency."
Benzodiazepines like triazolam and temazepam have been maligned in the press for being both habit-forming and addictive, but Dr. Wood says if someone tries hard enough any drug can be abused.
“There is a difference between dependence and addiction," she says. “There are some people who can be on the same benzo dose for years.
The drug probably isn’t doing much of anything anymore, but it you take it away these people will suffer withdrawal. Others might experience some enjoyment out of it and may begin to abuse their medication, taking higher doses and mixing it with alcohol or other dangerous substances. It depends on the person so the physician must be attentive."
The irony for Dr. Wood is that anything related to sleep is going to cause some amount of dependence or habituation. “Everything to do with sleep is a ritual. There are bedtime routines like brushing your teeth and washing your face. The entire sleep process involves patterns and cycles. It should come as no surprise that taking a sleeping pill may possibly become part of the routine."
Education is important. Dr. Wood recommends physicians talk to their patients about good sleep hygiene habits like going to bed at the same time every night and remembering the bedroom is a place to sleep. “It takes practice and time," she says. “Learning to practice good sleep hygiene is like learning to eat better and be fit. It’s a lifestyle change."
© Copyright 2008. Canadian Psychiatry Aujourd’hui. All rights reserved.
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