Prescribing sleep aids wisely

In the current medical culture, demands on our time may make it easier to give a patient a sleep aid the first time they ask, but it isn’t always the best practice.

I treat patients with insomnia every day in our sleep clinic. More and more patients, regardless of sleep disorder, are complaining of difficulties falling asleep, maintaining sleep or waking early. Unfortunately, many patients come to us already on sleep aids and are reluctant to stop using them. Let’s take a moment to review which treatments are appropriate to use and when.

Before prescribing any sleep aids, patients should complete a sleep diary for at least one week, preferably two or more. This will provide relevant information as to what behavioral problems may be present and other factors that may be causing sleeplessness.

Information recorded in the sleep diary should include the patient’s activities prior to bedtime, the length of time it takes to fall asleep, bedtimes and waking times and the number of awakenings he or she experiences each night. Going over this information will provide an opportunity for you to talk to the patient about proper sleep hygiene. Education alone usually helps a great deal.

Other questions to ask include whether patients have been using over-the-counter sleep aids like melatonin, or if they have tried relaxation techniques or meditation before bed. These promote sleep, so suggest patients try these methods first.

The gold standard and most clinically validated insomnia treatment remains stimulus control therapy.[1] Stimulus control is good for both patients who have trouble falling asleep and those that have difficulty maintaining sleep.

Stimulus control therapy limits the time that a patient spends awake in bed and includes sleep restriction. This should also be tried before putting a patient on sleep aids.

This advice does not mean that sleep aids have no place in treating insomnia, but rather that they should be used short term. Older sedating antidepressants, such as amitriptyline, doxepin and trazodone, should be prescribed before hypnotics. Too many patients are put on hypnotics as first-line therapy with out any sleep hygiene education and are kept on them for months or years at a time. In my experience, it is much easier weaning a patient from an anti-depressant than a benzodiazepine or a hypnotic.

If you do chose to prescribe hypnotics, know the half-life of these medications. If a patient has trouble falling sleep but can stay asleep, short-acting zolpidem can be helpful. However, if a patient has trouble falling asleep and staying asleep, a longer-acting medication such as eszopiclone is a better choice.   

I’ve put together a handy reference guide below for some of the more popular sleep aids. Notice that some of these have very long half-lives. Consider how many of your patients may be getting up for work each morning and driving with these medications still in their system.

Compare the available choices when making a decision about which your patient should receive. In the current medical culture, demands on our time may make it easier to give a patient a sleep aid the first time they ask, but it isn’t always the best practice.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.