Dr Kevin McCarroll
Medical Matters
Last September the Medical Council issued warnings about the over-prescribing of medications for anxiety and insomnia. Belonging to a class of drugs known as benzodiazepines, they first took prominence in 1963 with the arrival of Valium, a safer and better alternative to hitherto existing hypnotics. Its use skyrocketed along with newer versions in its class to become one of the most popular prescription medications worldwide. Now in the same genre of tablets is ‘Xanax’ also used for anxiety as well as a number of sleeping tablets.
While not known initially, it later emerged that dependency could develop quickly and over time tolerance, meaning higher doses to achieve the same effect. In fact, benzodiazepines should not be prescribed routinely for any more than 2-4 weeks precisely for this reason.
So how do they work? They act by boosting the effect of an inhibitory neurotransmitter (GABA) in the brain thereby dampening activity in areas like the amygdala which is linked to anxiety. But they also have more global effects sedating other brain areas as an unintended consequence.
In practice, trying to limit or reduce dosing can be difficult especially in those who suffer with major anxiety or insomnia and develop dependency. A typical example might be someone who goes on treatment after a bereavement but lack of access to psychotherapy or counselling means that they may become reliant on tablets. Indeed, they may even turn to the internet to get supply. Then when it comes to stopping there may be concerns about withdrawal side effects including rebound insomnia, tremor and feelings of panic.
Indeed, a problem that has arisen in recent years is a ‘black market’ for tablets like Xanax that in many cases contain dubious ingredients. In fact, such is the demand that there has been several large seizures of counterfeit medications.
In the 1990’s, a new class of tablets for sleep called Z drugs (zopiclone and zolpidem) also became popular. Though working in a similar way, they have a shorter duration of action and are considered to have a better side effect profile. For example, they are less likely to produce a “hangover effect” the next day and for this reason their use has increased significantly over the last decade as an alternative to benzodiazepines. However, tolerance, dependency and withdrawal symptoms can still occur.
Overall, it’s estimated that about a third of all benzodiazepine use is long-term with older adults accounting for the greatest proportion of these patients. A recent report found that Ireland had the highest rate of chronic benzodiazepine use (in the over 65s) among OECD countries. In fact, about 7.5% of this group were on treatment for over one year, yet are more sensitive to side effects including daytime drowsiness, confusion, falls and road traffic accidents. Some studies point to regional variation in the rate of use with a difference of up to threefold reported in one small investigation in Ireland. This may reflect in part differences in clinical need but also prescribing practises.
But anxiety and insomnia are common and in at least more severe cases, tablets may be needed to help get someone over a difficult period. As an alternative for generalised anxiety a class of antidepressants similar to ‘Prosac’ also work well.
For chronic insomnia, always try and look for causes before reaching for tablets. Some bodies recommend cognitive behavioural therapy as an initial treatment combining education on sleep hygiene with changes in behaviour. Unfortunately, such a holistic intervention is hard to come by but addressing some simple factors may greatly help.
For example, try and keep your sleep for bedtime only and establish a regular time for getting up every day. It’s important to wind down in the evening and avoid anything which is mentally demanding or too stimulating at least 90 minutes before bedtime – so choose your TV and reading material carefully! Avoid using smartphones or other devices at night which emit blue light. Drinks that contain caffeine may keep you awake and alcohol, though helping to get you off to sleep, can reduce your sleep quality and result in you getting up to go the toilet. Make sure the bedroom is well darkened and quiet and not too cold or warm. If you’re awake for more than 20 minutes consider getting up and even going to another room.
In summary, sedative hypnotics in the benzodiazepine class should only be used for about 2-4 weeks unless otherwise necessary. Sleeping tablets also reduce sleep quality with less time spent in the deeper or REM phase of sleep. Some studies also suggests that long-term use might increase the risk of dementia but research is conflicting. If you take tablets for anxiety or insomnia, consider talking to your GP about the option of reducing the dose and/or stopping.
Dr Kevin McCarroll is a Consultant Physician in Geriatric Medicine, St James’ Hospital, Dublin.