New guideline for sleeping pills may change doctors' prescribing habitsLet’s say you go to the doctor hoping to get a prescription for sleeping pills to relieve your insomnia. You’ve been through cognitive behavioral therapy and it has helped. But there are nights when you’re wound up so tightly that nothing—push-ups, meditation, a hot bath—will calm you down enough so you can get a decent night’s sleep. What then?

The American Academy of Sleep Medicine recently released a clinical practice guideline for the medical treatment of chronic insomnia in adults. Here’s what the academy now recommends.

Why the Need for a Clinical Practice Guideline?

Most experts in sleep medicine are well acquainted with the literature on sleeping pills and know how to diagnose and treat insomnia. When medication for insomnia is warranted, they know the best drug to prescribe based on your symptoms and medical history.

But most people with sleep complaints take them first to primary care providers. And when it comes to prescribing sleeping pills, not all doctors are on the same page. In fact, a new study from Harvard Medical School shows that, rather than prescribing based on individual patients’ symptoms and history, many doctors find one or two sleep medications they’re comfortable with and prescribe the same drug or drugs again and again.

The new clinical practice guideline contains recommendations that are evidence based. It has the potential to change physicians’ prescribing habits and thus to affect people with insomnia who use sleeping pills, now and in the future.

The Guidelines Are Based on Weak Evidence

The four sleep experts who created the guideline first conducted a literature review. They concluded that no sleeping pill or sleep aid on the market today has been tested in multiple clinical trials and found to be extremely effective and carry very few risks. So the evidence base for their recommendations is, they note, “weak.”

This doesn’t mean that a given medication would not be appropriate and effective for a particular individual with insomnia. It just means as a general treatment for everyone with chronic insomnia, no sleeping pill is backed up strongly by the evidence.

These Sleeping Pills Got a Thumbs-Up

Perhaps predictably, the medications judged to be appropriate—based on the quality of evidence, the balance of benefits and harms, and patient values and preferences—are medications approved by the FDA for the treatment of insomnia. The guideline does not suggest that one drug is better than another since so few studies comparing the efficacy of two or more sleeping pills have been conducted. So the medications listed here are in no particular order:

MEDICATION

SLEEP ONSET INSOMNIA

SLEEP MAINTENANCE INSOMNIA

suvorexant (Belsomra)  X
eszopiclone (Lunesta) X  X
zaleplon (Sonata) X
zolpidem (Ambien) X
triazolam (Halcion) X
temazepam (Restoril) X X
ramelteon (Rozerem) X
doxepin (Silenor) X

These Sleep Aids Were Not Recommended

The following medications and supplements are sometimes prescribed and used for chronic insomnia. Depending on an individual’s symptoms and history, they may help. But the published data on these substances is insufficient in quantity and/or quality to warrant a recommendation for general use as a treatment for chronic insomnia.

  • trazodone (a sedating antidepressant)
  • tiagabine (an anticonvulsant approved for the treatment of epilepsy and used off-label to treat anxiety and panic disorders)
  • diphenhydramine (the antihistamine found in most over-the-counter sleep aids, including ZzzQuil, Sominex, and Tylenol PM)
  • tryptophan (a supplement containing an amino acid found in milk and other sources of dietary protein)
  • melatonin (a supplement which is bio-identical to a hormone produced in the body, useful for jet lag and delayed sleep phase disorder)
  • valerian (a plant-based supplement)

If you’ve used any of these medications or supplements, how effective were they, and did you experience any side effects?

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.

4 Comments

  1. Really interesting report in JCSM I thought. As you noted, the strength of all the recommendations was “weak”. Also, the recommendations were compared to no therapy (doing nothing), and even then some substances were noted to do “more harm than good”. I thought it was interesting that Halcion was even on the list, or for that matter Tiagabine. Haven’t seen a patient on either of those for insomnia in at least 10 years. And Trazodone was not recommended but I see it prescribed frequently because it seems to be fairly non habit-forming. And as you pointed out, very few good head to head drug trials have been done.

    CBT, with other contributing issues addressed, really is the answer for chronic insomnia in my opinion. Gets to those perpetuating factors, which is key.

    Like

    Reply

    1. Hi Michael,

      Thanks for your comments. Halcion may have been included in the review because, although it caused quite a brouhaha in the late 1980s and early 1990s, it WAS approved by the FDA for the treatment of insomnia and remains on the list of drugs approved for insomnia.

      As for tiagabine, I was a little surprised to see it on the list, too. Yet I know the four sleep experts who reviewed the literature and produced the guideline are very knowledgeable about sleep medication—they’re just the ones I’d entrust to produce evidence-based recommendations on which agents work and which don’t. They’re probably in-the-know about physician prescribing habits as well. This is the point where I think they must know something I don’t know.

      Thanks again!

      Like

      Reply

  2. As someone who had a circadian disorder that was indomitable for ten years (and now finally found some ways to sleep), my personal experience very much contradicts this. Some of the sleeping medications recommended here were extensively tried, did not help at all and very much made my life worse. Zolpidem would make me extremely drunk, hallucinate, do silly stuff, give me amnesia – basically everything but sleep *and* deteriorate my brain and gut health.
    Melatonin and tryptophan, while they would do nothing to me by themselves, became very helpful once I got my light regimes (blue light and amber light) in place. That’s just how it was for me. After Many years of trying everything.

    Like

    Reply

    1. Hi Marta,

      It must have been terrible to live with a sleep disorder that was misdiagnosed for 10 years! But it’s fairly common for people to mistake a circadian rhythm disorder for insomnia. Unfortunately some doctors are uninformed about the distinction and will prescribe sleeping pills even though sleeping pills are inappropriate for people in your situation. I’ve posted a blog about this very thing:

      https://thesavvyinsomniac.com/2015/12/14/qa-should-night-owls-use-sleeping-pills/

      The new guideline I’ve written about above is intended to help doctors treating patients who have been (correctly) diagnosed with insomnia disorder. None of the sleeping pills listed above would be appropriate for a person with a circadian rhythm disorder.

      Thanks for bringing this issue up.

      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