#79 - Skills Not Pills: The Limits of Sleeping Pills
“Medication is probably the only solution to sleeplessness”.
This isn’t what I heard someone say - but rather a statement on a questionnaire that measures a person’s beliefs about sleep.
I was reminded of this statement - and many more - as I’m developing WINK’s 2nd online course (Advanced Cognitive Therapy for Insomnia).
This statement was developed by Prof Charles Morin - one of the leading insomnia gurus in the world.
He developed this statement - and many more - based on his years of experience listening to people experiencing insomnia.
Many people who experience sleeplessness may eventually see their trusted doctor for help.
Doctors have been trained in the ‘medical model’. They have incredible knowledge and expertise when it comes to medications for sleep. Plus, they’re also bombarded by pharmaceutical companies throughout their training and professional career.
We’re often hearing that they receive very little training in sleep.
This likely means that they miss out on knowing the pros, the cons, and the alternatives to sleep medications.
How about you?
Mogadon
“I need to have my Mogadon with a couple of beers every night otherwise I won’t sleep” - said the large Scottish woman who reminded me of a female version of Fat Bastard from the Austin Powers movies.
I had no idea what she was talking about.
Not because she was Scottish. But because I didn’t know what Mogadon was. I was early in my training and had not heard of it.
“It’s a horse tranquiliser” said my mentor Prof Leon Lack behind his quizzical smirk.
Mogadon is a benzodiazepine that is indicated for the short-term treatment of insomnia. Because it has a long half-life (24 hours - give or take), it can build up in one’s body.
Let me explain that another way. Imagine you take a Mogadon to fall asleep on Sunday night. When it’s Monday night, you’ve still got 1/2 a dose of Sunday night’s Mogadon in you. That’s what the half-life of 24 hours means. 24 hours later you’ve got half the dose in you.
If you keep taking 1 Mogadon tablet each night, all week, here’s what happens…
Monday you have 1.5 tablets in you.
Tuesday you have 1.75 tablets in you.
Wednesday you have 1.88 tablets in you.
Thursday you have 1.94 tablets in you.
Friday night … you get the picture, right?
You’ve always got Mogadon in you.
Thus one common side effect from Mogadon is drowsiness during the day - making it hard to do things like ‘be awake’ and ‘drive’.
Because people could not function well during the day whilst taking Mogadon at night, many would think ‘What’s the point?”. Their insomnia meant they weren’t functioning well anyway.
So Mogadon didn’t improve their daytime performance - even if they did sleep better.
But Mogadon is not the only benzo for sleep issues …
Temazepam
Unlike Mogadon’s 24 hour half-life, Temazepam has a half-life of about 8 hours. So there’s less chance for this benzodiazepine to build-up in your system.
Nevertheless, there’s still some Temazepam in you when you wake in the morning - and some people notice that they feel groggy when they wake up.
That’s certainly what I experienced.
When flying eastward to North America, my ‘owl-like nature’ goes into overdrive and I fall asleep around 4 AM at the start of my trips.
So for the first few nights I take Temazepam to lessen the pain of jet-lag.
But damn ! I’ve done a morning talk at a conference with Temazepam in my system. Never again !
Anyway, rather than completely bag sleep meds - which is basically what this post is about - let’s look at the evidence for temazepam treating insomnia.
A recent review has shown that Temazepam:
increases sleep duration (by about 20 min),
decreases the amount of time awake during the night (by about 20 min),
but does no better than a placebo pill when it comes to falling asleep at the start of the night.
This last finding may come as a surprise to many of you - because in all truthfulness - it’s a surprise to me. And another good reason to keep up with the research!
There may even be some of you - like me - that know of studies that show Temazepam was better than a placebo pill.
But the graph below from this 2021 review by Chiu and colleagues shows that the range of findings from studies (the horizontal line) is both in the negative (better than placebo, because it decreases the time take to fall asleep) and the positive range (worse than placebo) - which is probably why the overall effect (the small grey dot) is close to the zero line.
The recommendation is to only use Temazepam in the short-term (ie, 4 weeks).
This is because our brains can tolerate to the effects of benzodiazepines.
And when we become tolerant, those sleepy effects begin to wear off.
So because the effectiveness of benzos is linear (ie, the more you take, the more it works), people then begin to take more than their recommended 10mg tablet - in order to regain that good night sleep.
But you cannot keep taking temazepam in a linear way. It could take you to Coma Avenue (or worse).
This is why you should stop taking Temazepam after 4 weeks.
But …
Rebound Insomnia
Right back when Gordon Gecko was claiming “Greed is Good” (aka, 1987), people were reporting on the effects of a phenomenon called ‘rebound insomnia’. An occasion where ‘insomnia’ experienced in response to humans ceasing their intake of benzodiazepines.
My sleep practice got to a point where so many people were ‘hooked’ to Temazepam that I started asking them questions - like:
“Did your GP ever teach you that you can experience rebound insomnia if you suddenly stop taking Temazepam?”
I can’t think of a single occasion where a client said “Yes”.
And because of this, people with insomnia believe - in order to sleep well - they need to take a sleeping pill.
Let me say that another way.
When they stop taking Temazepam, they immediately experience rebound insomnia, and then they go back onto Temazepam.
I saw so many clients that were on Temazepam for years …
How To Get Off Temazepam?
There’s a few ways to do this:
Gradually taper oneself off Temazepam under medical supervision (most common).
With help from cognitive behaviour therapy for insomnia.
Both of the above (Morin et al., 2005).
Because of the tolerance, dependence, and risks of taking too much Temazepam - some people were looking for alternative psychopharmacological agents to help people sleep.
Stillnox / Ambien
Zolpidem (known as Stillnox in Australia - and Ambien in the USA) was a new medicine to help people sleep.
Unlike Temazepam, it was not suspected of producing tolerance and dependence.
But. People did not expect it to do something else.
Bizarre sleep behaviours.
Ones that were dangerous. That sometimes meant that people died…
There were reports of people ‘sleep eating’, ‘sleep driving’, and ‘sleepwalking’. Behaviours they had never shown before. And tragically, some of these people crashed their vehicles, fell off balconies and bridges.
But it wasn’t until someone famous died, that attention was focused on the potential dangers of Zolpidem.
Whilst Heath Ledger had recently used Stillnox - and there was a lot of media attention attributing his death to Stillnox, a toxicology report found no traces of it at the time of his death.
Instead, the toxicology report found a number of pharmaceuticals in Heath Ledger - including multiple benzodiazepines - one being Temazepam.
Nevertheless, a month after Heath Ledger’s death, the Therapeutic Goods of Australia (TGA) slapped a warning on the boxes of Stillnox - alerting users to the potential of ‘complex sleep-related behaviours’.
Of the ~1000 reports to the TGA, 105 of these were people reporting sleep driving.
I’m glad I catch the bus…
How Does CBT for Insomnia Compare?
One of the earliest direct comparisons between sleep medications and non-pharmacological treatments for insomnia was published in 2004.
The researchers found that CBT for Insomnia outperformed Stillnox.
Most importantly, the sleep benefits for those who learned CBT for Insomnia lasted for a further 2 years after treatment.
For those who were prescribed Stillnox, they did receive sleep benefits - however - because they had to eventually stop taking Stillnox, their good sleep quickly turned to bad sleep.
Even though 17 years has passed since this seminal study, it is surprisingly difficult to find additional head-to-head comparisons between CBT for Insomnia and Zolpidem. Most studies now compare CBT vs CBT plus Zolpidem - almost like Zolpidem needs CBT in order to do its job.
Conclusion?
In our Brief Behaviour Therapy for Insomnia course, I speak about Short-Term Insomnia vs Long-Term Insomnia.
Short-Term Insomnia can occur when people undergo a stressful life event. To cope with this acute insomnia experience, people could use sleeping tablets in the short-term (eg, 4 weeks or less) - assuming they’re a suitable fit for that medication, and they are advised by their doctor how to taper off it.
Long-Term Insomnia occurs when people ‘learn’ unhelpful ways of coping with their Short-Term Insomnia. The stressful life event can subside, yet their insomnia persists.
The evidence shows that CBT for Insomnia can help - and produce long-term benefits.
Again, this is because CBT teaches people skills. Techniques that they can re-implement down the track when insomnia strikes again.
Prof Michael Gradisar
Completion of this course provides you with the certified “BBT-I Practitioner” title and badge.
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