I have often said that I am in favor of a cautious and moderate use of medication on an as-needed basis—mainly as a source of comfort for those with severe sleep anxiety. I described what had been my own medication regime—taking one 0.5-mg tablet of lorazepam (Ativan) no more than 2-3 times per week over a period of 1-2 months. This allowed me to get over the very worst part of my sleep-anxiety-induced chronic insomnia while I retrained my brain to become less anxious over my lack of sleep through cognitive behavioral self-therapy techniques.
It worked for me, and I did not suffer from any long-term effects of using medication in this way, so I did not feel too concerned about encouraging people to go ahead and try what I did to get some much needed relief from the rock-bottom levels of sleep anxiety.
Now, however, I feel the need to revise my comments to add some cautionary statements, based on new information I have received.
Recently a site visitor emailed me about the dangers of benzodiazepine addiction, which caused me to rethink some of my recommendations about these drugs.
Benzodiazepines, or “benzos” for short, are a family of pharmaceutical drugs that include anti-anxiety medications (sometimes they’re referred to as “tranquilizers”) and a few sleeping medications. Here is a long list:
- Alprazolam (Xanax)
- Bromazepam (Lexotan, Lexomil)
- Chlordiazepoxide (Librium)
- Clobazam (Frisium)
- Clonazepam (Klonopin, Rivotril)
- Clorazepate (Tranxene)
- Diazepam (Valium)
- Estazolam (ProSom)
- Flunitrazepam (Rohypnol)
- Flurazepam (Dalmane)
- Halazepam (Paxipam)
- Ketazolam (Anxon)
- Loprazolam (Dormonoct)
- Lorazepam (Ativan)
- Lormetazepam (Noctamid)
- Medazepam (Nobrium)
- Nitrazepam (Mogadon
- Nordazepam (Nordaz, Calmday)
- Oxazepam (Serax, Serenid, Serepax)
- Prazepam (Centrax)
- Quazepam (Doral)
- Temazepam (Restoril, Normison, Euhypnos)
- Triazolam (Halcion)
The following is a list of non-benzodiazepines with similar effects [that may also cause dependency and withdrawal–as you can see, included are the most commonly prescribed sleeping pills]
- Zaleplon (Sonata)
- Zolpidem (Ambien, Stilnoct)
- Zopiclone (Zimovane, Imovane)
- Eszopiclone (Lunesta)
[Source: benzo.org.uk/manual/]
Many of these drugs have few noticeable side effects and therefore have often been considered benign and mild-acting in low-to-moderate dosages. Of course, it is common knowledge that they can cause serious dependency and addiction when abused, misused, or taken daily over a long period of time. I also knew that dangerous withdrawal symptoms can occur when the misuse is stopped suddenly.
But what I didn’t know, and what my email correspondent was informing me, was that addiction and dependency can happen, for a sizeable minority of the population, at lower dosages and within much shorter timeframes than I had previously known.
For this group of susceptible individuals, the drugs are definitely NOT benign. They are, in fact, quite dangerous and can cause untold misery and harm. Since it is impossible to know ahead of time whether any individual falls into this group, doctors routinely prescribe these drugs, not knowing or understanding the potential for bad effects. Since my own recommendations could potentially contribute to someone getting on the wrong track, I am posting this cautionary article.
My correspondent granted me permission to quote from the email I received, as this person presented the case far more clearly and eloquently than I could:
I would like to point out something that is overlooked for some reason by all sleep experts that I have met so far. It has to do with benzodiazepines (=prescribed sleeping pills) and how they damage the central nervous system with chronic use.
This damage is not permanent, but in an estimated 15 % of users it can take many months or even years after the last dose before the neuroreceptors are restored. During this time, sleep will be very difficult to come by, regardless of how much behavioral changes you make or how much relaxation techniques you practice. The problem cannot be solved with CBT because it is not psychological in nature. Downregulated neuroreceptors are causing it, and it takes a lot of time for them to upregulate.
I know this for a fact because I’m currently in that situation and my insomnia is out of this world. Certainly worse than anything that is possible without medication or withdrawal from medication.
Benzodiazepines in particular are more addictive than street drugs and alcohol, and the withdrawal period is often complex and protracted. It is true that taking a benzo occasionally will not harm you, but 2-3 times a week is risky at best, and it will eventually lead to physical dependency and withdrawal. Sending an insomniac to a doctor or a specialist [can also be] dangerous advice, since most doctors are not aware of the dangers of sleeping pills, nor are they trained in any way to get you off them. Trust me, I know.
I would like to refer you to the Wikipedia articles on benzodiazepines, benzodiazepine dependence and withdrawal, protracted withdrawal syndrome, and substance kindling.
Also, have a look at the Ashton Manual, which can be found online. It contains valuable information about insomnia as a result of prescribed drug withdrawal.
Insomnia and Withdrawal
In a second email, my correspondent went into more details about the intractable, long-lasting, hard-to cure, and frustrating insomnia that was a result of withdrawing from medication, a cruel irony, since so many people start taking these drugs in order to sleep better:
I’ve been totally med-free for 22 months now and the withdrawal has been brutal. I could not have slept more than 3 hours average all this time, with many nights not even that. I still have frequent nights with zero sleep. Even the hours that I do get are usually of very poor quality with frequent awakenings. My best nights are 5-6 hours of broken sleep, and this is regardless of the fact that I only spend 6-7 hours in bed and often less than that because I get up a lot. I walk… I eat only healthy things and am pretty sure I’m doing everything else right to guarantee enough sleep. Sleep just doesn’t come, and insomnia is just one of the so many other symptoms I have to deal with on a daily basis. I also have all the neurological problems, sensory disturbances, muscle pain and weakness, headaches, and during my first year off also intense anxiety, panic attacks and agoraphobia. Never experienced anything like it before the benzos.
All I can say is, I have great sympathy for anyone experiencing any of these symptoms. I was further alarmed at what my correspondent had to endure during attempts to seek help from the medical/psychiatric community for terrible insomnia and other symptoms:
No doctor ever suspected the benzos and I ended up in psychiatry, where all my horrible symptoms were regarded as mental illness and “treated” with antipsychotics and antidepressants, which to the surprise of the 10-some psychiatrists that I saw, never put me to sleep. I had never had any history of psychiatric illness before and had been basically healthy with only some minor problems like the average person. Now these benzos had turned me into a physical and mental wreck….
…The ignorance about benzo dependency and withdrawal within medical circles is appalling. Psychiatrists… never address the underlying behavioral problems and simply drug you up with all kinds of pills, which in many people create more problems than they actually solve. In fact, they don’t solve anything. They just cover up your symptoms, if you’re lucky. Mine didn’t even do that.
I’ve spent hundreds of hours on online support forums for people having trouble getting off their sleeping pills, and what you read there is unbelievable. Hardly anyone is able to find a doctor who understands and who is knowledgeable about benzos. Most people were prescribed benzos long term and then told to stop taking their tablets all at once, and many of them did and ended up on disability for years. The withdrawal process doesn’t need to be a hellish experience if you do it right from the first time, but once you start going off and on benzos like I was forced to do in the different hospitals that treated me and suffered multiple cold turkey experiences, your central nervous system gets very sensitive, and you’re usually in for a very long recovery time. A few years in most cases.
In response to this email, I have read through the Ashton Manual and it seems to be a very helpful resource for anyone going through the painful misery of benzodiazepine withdrawal, written by an expert with many years of experience guiding people through the rehab process. Dr. Ashton also gives lots of information about the nature of benzo-drugs, how they act on the brain and nervous system receptors, and why they can cause the damage that they do.
Revisions
So at last, here is my revised commentary on sleeping medication based on my recently acquired knowledge:
First, become better aware of the dangers of benzodiazepines and similar-acting drugs such as those developed especially for insomnia. The stories of people who had to go off these drugs are probably the best deterrent to misusing them.
Even after hearing of the dangers, it is difficult for me to say “never take these medications,” because I did receive temporary benefit from them at some very crucial times in my insomniac history. I would consider it hypocritical to warn others while I reaped my own benefits through occasional use.
So I will say this: if you are suffering from serious sleep anxiety and feel you really need medication to help you get at least one or two good nights once in a while, mainly to interrupt the snowball effect of fear and stress, that’s fine—get some medication but use it sparingly, meaning, no more than twice a week and in the lowest dose possible, and no more than one month at a time. This is especially important if you have never taken them before and have no experience with your response.
In my own case, I discovered that I could get results from Ativan by breaking my 0.5 mg. pills in half. You may want to cut all the pills in your bottle so they will be ready when you need them.
If you find yourself taking these medications more than twice a week or longer than a month, stop and reevaluate what sort of habit you’ve gotten into. Have you been reaching for the pills instead of working on the real causes of your insomnia, including sleep anxiety, faulty sleep schedule, poor sleep hygiene and so on?
You need to become a truthful friend to yourself… and you need to begin the process of lessening your doses and spacing them further apart, and then giving yourself at least a med-free month.
If you have already been taking these medications very regularly, such as between 2-3 times per week, every week, for a month or more, DO NOT stop taking them cold turkey. Taper off slowly, in both frequency and dosage over a period, paying attention to your body. If you experience rebound insomnia and anxiety, it is possible that you are tapering off too quickly. If you are simply experiencing your normal insomnia and sleep anxiety, then you are probably fine (well, at least as far as dependency goes).
If you feel that your current insomnia may be a result of recently stopping a regular pattern of taking pills, you could take a look at the Ashton Manual for more guidance of how to treat your withdrawal symptoms.
About Doctors…
This issue is a bit tricky. As I said to my email correspondent, as the owner of health-related site, albeit a small one, I can not warn visitors against consulting medical professionals when they need help. However, I can say this:
If you go to a sleep specialist or other doctor requesting help for your chronic insomnia and you get nothing more than a prescription for medication with the words “take one a day as needed,” your best option is to tear up that prescription and make an appointment with a different specialist, one who understands your desire to treat the real cause of the problem… and one who won’t dismiss your complaints with an invitation to create more problems for yourself.
If you have experience with benzo-type meds and already know that you don’t fall into this group of susceptible people, then you can use your own good judgment and self-discipline to take them in a safe and temporary manner.
In the End
I have always maintained that my goal with this site is to offer comfort and sympathy along with a few good ideas on how to treat one’s own insomnia. But it is especially aimed at those who, like me, turned an ordinary case of insomnia into a full-fledged “disorder” because of obsessive worrying. This is the essence of sleep anxiety, and it is mainly this condition in that my site is designed to address.
So I will point out, again, that I have no qualifications to give out advice, but I do like to present the facts and knowledge I learn as accurately and thoughtfully as possible. Hopefully, I have done that here.