Insomnia sufferers who use sleeping pills can taper off them while undergoing cognitive-behavioral therapyA long-term user of sleeping pills wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia.

“Before I go through CBT, will I have to give up my sleeping pills? I’d like to get off them eventually, but every time I think of doing it I freak out.”

Some sleep therapists ask people with insomnia to refrain from using sleeping pills while undergoing CBT, a treatment that promotes sleep-friendly practices and a positive mindset. But this rule may be hard to comply with for people who’ve used sleeping pills for months and years. So hard, in fact, that it may discourage them from trying CBT at all.

Recently I looked into research on insomnia sufferers going through CBT while at the same time tapering off (or reducing reliance on) sleeping pills. What I found was encouraging, so I’ll share it here.

Sleeping Pills? I Love Them!

My aim isn’t to convince people comfortable with their sleep meds to come off them. I use hypnotics occasionally myself, and frankly I get tired of people demonizing them as if they were on par with heroin or crack cocaine.

But some nightly users complain, even when taking sleeping pills, that their sleep isn’t very satisfying. This perception is probably related to the fact that many sleep meds, especially when taken over time, tend to change the nature of sleep. Also, studies linking long-term use of sleeping pills to increasing vulnerability to colds, depression and mortality are not reassuring. It’s easy to see why some long-term users are interested in a path to sleep that feels more “natural.”

Tapering Off Sleep Meds

If you’ve used hypnotics for a long time, it’s not a good idea to go cold turkey, say Lynda Bélanger and colleagues in a paper on hypnotic discontinuation. Stopping abruptly puts you at greater risk for withdrawal symptoms and health complications. Hypnotic drugs should be discontinued gradually, they say–ideally with guidance from a trusted physician.

No guidelines exist showing what the optimal rate of tapering is. Your doctor might propose decreasing the initial dose by 25 percent every week or every other week. But, say these Canadian researchers, the pace of the tapering “may need to be adjusted according to the presence of withdrawal symptoms and anticipatory anxiety; it can also be slowed if the person finds it too difficult to cope or feels unable to meet the reduction goal.”

CBT Assists Tapering and Improves Sleep

In most studies of sleeping pill users undergoing CBT for insomnia, CBT has helped wean them off drugs (or reduce the amount they use) and improved their sleep. Here’s a snapshot of the results:

  • CMAJ, 2003: About 77 percent of those undergoing CBT while on a drug tapering program came off their meds, vs. 38 percent on the drug tapering program only.
  • American Journal of Psychiatry, 2004: About 85 percent of those undergoing CBT while on a drug tapering program came off their meds, vs. 48 percent on the drug tapering program only. CBT groups also reported greater sleep benefits than the group doing the taper alone.
  • BMC Psychiatry, 2008: Added to a drug tapering program, CBT improved sleep quality in hypnotic users even more than it did in people who didn’t use drugs.
  • Sleep Medicine, 2014: In this novel study, adding hypnotic medication to traditional CBT improved subjects’ sleep faster than CBT alone. (By the end of therapy, the sleep of both groups had improved equally).

So if you’d like to try CBT but are anxious about stopping your sleep meds, shop around for a sleep specialist who’s willing to work with you to tailor a program suited to your needs. What’s not to like about the prospect of improving your sleep and at the same time reducing your dependence on drugs?

What concerns do you have about CBT and sleeping pills?

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg has worked with language for many years. She taught ESL, coauthored two textbooks, and then became a reporter, writing about health, education, government, Latino affairs, and food. Her lifelong struggle with insomnia and interest in investigative reporting motivated her to write a book, The Savvy Insomniac: A Personal Journey through Science to Better Sleep. She now freelances as an editor and copy writer at On the Mark Editing.

8 Comments

  1. I have had insomnia for 10 years, been on seroquel, ambien, klonopin, lyrica. Benedryl, all at different times . I finally made an appointment with a sleep therapist Jan 6. For CBT. I am so scared it won’t work for me. I’m really scared and wearing thin with the exhaustion . Do you have any advice?

    Like

    Reply

    1. Hi Jenny,

      Signing up for CBT for insomnia can be a scary step to take. Yet if you feel a rapport with your therapist, and if you’re like the majority of people who go through with the program, you’ll really be glad you did.

      I too was scared about trying CBT for insomnia. Not because I was routinely taking medication, but because the protocol seemed too rigid and exacting. I didn’t think I could ever sleep on a regular schedule.

      Chapter 8 of The Savvy Insomniac, my book, is in essence the story of how I felt going into CBT, and what the whole experience was like, for me and for others who also went through it. It was challenging, especially in the first week.

      But ultimately it led to sounder, more stable sleep than I ever thought could be possible for a person like me. So I encourage you to park your skepticism at the therapist’s door and go into the program wholeheartedly believing that improved sleep IS possible, and that CBT is the way to achieve it.

      If you haven’t taken a look at this blog, you might find it helpful:

      http://www.thesavvyinsomniac.com/sleep-restriction-what-you-need-to-succeed/

      Before signing off, I’d like to congratulate you on finding the courage to think it possible that you could manage your sleep without medication. And I wish you the very best of luck.

      Like

      Reply

  2. I have had chronic insomnia for about 20 years. After my dad died in 2008 it got worse and I started taking zolpidem 10mg every night (5mg didn’t help). It really helped my sleep and improved the quality of my life greatly. I know it has gotten a bad rap especially at the higher dose, but I had no adverse effects. In fact the opposite is true, I functioned at a much higher level. I did go through CBT at our local hospital which is a huge University facility. I found very little help from it. Recently my employer offered a program called SHUTI (sleep healthy using the internet) to employees that would be willing to commit to doing it COMPLETELY otherwise you would have to pay them back. I thought I had nothing to lose so decided to try it. I am doing it now and I have to say this is a super program. I feel like I am getting so much more out of it than even the 1:1 CBT that I got back in 2008. It is so easy to follow, there is not the stress of having to make and keep appointments. You do it whenever you want from the convenience of your own home. There are sleep diaries to fill out, but they are so much easier than what I had before. After a week of diaries they give you a “sleep prescription” based on what time you need to wake up that tells you when to get in bed. Yes, it can be hard to follow. BUT DO IT. All I can say is it works. The program is very informative and interactive, using vignettes and video clips of doctors explaining things. The program can be done with or without your sleep med. I am doing it with my medicine, but honestly for the first time in 8 years feel like I could actually attempt and succeed at getting off the zolpidem. I got lucky and my employer offered it to us for free, it may cost you something but I think it would be worth it. Google it and check it out. We will see where it goes, but I encourage people to look into it and do it with all your heart, what do you have to loose?

    Like

    Reply

    1. Hi Krista,

      This is quite a ringing endorsement of the SHUTi program! Thanks so much for sharing your experience here. I’m sure it’ll motivate others to give the program a try.

      Like

      Reply

  3. I have to say I am amazed at what you are doing here. Thoughtful responses to every single person. I can’t even keep up with replying to personal emails.
    So would you say that SR should be the last resort? I’ve read hundreds of the comments now and it seems like everyone has tried everything before SR. I’m not sure if I should keep trying with these quick fixes before starting SR. When I say quick-fixes I mean all other advice such as blue-blocking glasses, herbal supplements, hygiene etc. They don’t seem to require the commitment that SR does (so one naturally wants to try them first). About a month ago after reading up on Ambien I concluded my long-term use of it (and possibly the 2 glasses of wine I was drinking every single night) has caused the brain fog and trouble learning that I have been experiencing for over a year. Since then I’ve stopped drinking and been in the process of doing everything I can to improve sleep. I made progress and was able to taper down to 2.5mg of Ambien. Last night I proudly stopped taking it, and then slept only 1 or 2 hours. In the furious AM googling that followed is when I found your blog. I had been looking up more info on supplements/herbals to take and just ONE person made some comment about SR.
    A few months ago a sleep study doctor told me to take Melatonin after my sleep apnea test came back as just mild. Then few weeks ago I read it’s only to be used occasionally. So that’s another pill I need to taper off I guess. Of all these supplements that I’ve tried that only work a little, I found GABA powder really relaxed me the one time I tried it. So now that I’m off the Ambien I may try that.

    Like

    Reply

  4. Hi Eric,

    Thank you for your appreciation of this blog. I do try to respond to every comment and I hope the responses are at least somewhat helpful.

    It sounds like you’re already taking steps that will lead to better sleep and a clearer head during the daytime. Good for you. Believing that change is possible means you’ve won at least half the battle.

    You raise lots of issues here. If you’ve used Ambien a long time, it doesn’t surprise me that on your first night of not taking it, you had a poor night’s sleep. This is called rebound insomnia, and it’s the reason so many people who try to stop taking sleep meds find themselves going right back on the pills they were trying to stop.

    I’ve never taken any sleeping pill on a nightly basis, so I can’t tell you what to expect. But I do take Ambien occasionally, for one or two nights at a time. The night I stop taking it, I notice my sleep isn’t so great. But the next night, I usually sleep well.

    Regarding melatonin supplements, they’re effective in a few situations. One, if you’re a night owl and want to be able to fall asleep at an earlier hour, you can take the supplement around dinner time. If you go to my blog and type “melatonin” in the site search box, you can read more about this.

    Two, they can be used to mitigate jet lag. And three, sometimes older people aren’t producing enough melatonin themselves, and a supplement helps. But melatonin supplements are not sleeping pills and do not have the same negative side effects. MT is considered safe for long-term use. But if what you have is simple insomnia, very likely MT won’t help.

    For me, sleep restriction therapy was a last resort. But I wish I’d been game to try it much sooner than I did. Sure, it was as difficult as I imagined it would be during the first week of treatment, and the progress I made wasn’t exactly linear.

    But now, 9 years after trying it, I can say that because of SRT, my sleep is light years ahead of where it was before. I am much more resilient to situations that would have triggered long bouts of sleeplessness before. So I’d encourage you to try it! (But read up on it first so you give yourself the best chance of success.)

    Regarding the GABA powder, I don’t know enough about it to comment on it. So I’ll leave it at that.

    Best of luck in your pursuit of sounder sleep and clearer thinking!

    Like

    Reply

  5. Hi Lois,

    This is exactly what I needed to see! I’m tapering off clonazepam after 6 weeks of use (the neurologist/sleep specialist is not supportive of me getting off) and had no idea where to find information about whether I could start CBT-I while tapering. It’s so great to know that there is a high success rate for both simultaneously!

    Kind regards,
    Laura

    Like

    Reply

    1. Hi Laura,

      Given your evident interest in trying CBT-I, I hope you’re able to find a therapist trained in behavioral sleep medicine (CBSM) who can support you as you’re going through therapy and tapering off the clonazepam. This blog post may help you find the right person:

      https://thesavvyinsomniac.com/2016/12/28/improve-your-sleep-with-cbt/

      Like

      Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s