There are many common side effects of sleeping pills but the most familiar among all the sleep inducers is alcohol, and everyone knows that a large quantity of alcohol can make you fall over while walking, or have an accident while driving a car.
Common sense and a lot of research tell us that smaller quantities of alcohol have the same kinds of effect, but in smaller degree, and that the effects are proportional to how much drink has been consumed.
If you drink only a really small amount-say ½ pint/275 ml of beer -then by an extra effort of concentration you can compensate in part for the effects of the alcohol, but only to a limited extent.
Side effects of sleeping pills
All the other sleeping drugs resemble alcohol. They promote sleep as well as altering its detailed composition; usually, for example by reducing the proportion of time you normally spend in paradoxical sleep (not that you will be in any way aware of this, not be harmed in any way as a result).
In addition, they reduce anxiety; they make us unsteady on our feet slurred in our speech, inclined to have accidents; and they impair our usual good judgment.
One way of finding out if someone’s abilities are impaired by alcohol is to go out in a car driven by that person. We might not all want to. Another way is to ask someone who has been drinking to walk carefully, heel to toe, along a line.
Tests of skillful coordination like this are also used to see whether sleeping pills taken at bedtime leave unwanted effects during the next day. We have conducted many such experiments at our Edinburgh laboratories.
On the nights before the daytime tests our volunteers take a pill before going to bed. All the pills look identical, but known only to us, some are inactive and others are sleeping pills of varying types.
The volunteers come for two hours of tests in the morning, two hours of tests in the middle of the day and two hours of tests in the late afternoon.
Both sleeping pills and alcohol impair judgement. Someone who takes a drink to steady the nerves will not perform as well as he would have done had he abstained.
We ask them to pick up lead shot pellets as fast as they can and fit them into an awkward vertical tube at high speed for two minutes to see how many they can cram in.
We ask them to deal playing cards into two boxes as fast as they can. We ask them to sit with headphone on for an hour while performing a very boring task, during which they are supposed to listen for occasional special noises played through the headphones, and then to press a button when the noises are heard.
This test is designed to see how well they can maintain concentration despite the boredom. Tests like these can tell us when someone has taken a sleeping pill the night before.
Many of the modern benzodiazepine sleeping drugs such as triazolam(Halcion) or lormetazepam (Noctamid), have largely disappeared from the body’s tissues by breakfast-time and there may be little or no impairment of skill the next day, or, at the most, only first thing in the morning.
Other sleeping drugs, like flurazepam (Dalmane) also a benzodiazepine, if taken regularly, can build up in the tissues and cause sustained impairment of abilities throughout the day.
This is not yet fully realized by all doctors and flurazepam remains every widely prescribed, especially in the United States.
Many people take alcohol, barbiturates or benzodiazepines to calm themselves during the day. We all know how anxiety can make us inefficient. It is the basis of the old saying about the more haste the less speed.
The tennis player who can watch the ball to the middle of his racquets when he is relaxed, may play badly in front of a crowd on a great occasion, due to nerves.
Some argue, therefore, that if this anxious tennis player were to have a pre-match measure of whisky, or take a small dose of a barbiturate or a benzodiazepine-all of which diminish anxiety then he would play better than he otherwise might. It makes plausible story: taking a drink to steady the nerves.
Unfortunately the facts of real life do not support this rationale for taking alcohol, barbiturates or benzodiazepines. In general, bad nerves, plus drugs are worse than bad nerves alone, as far as objective skill is concerned, even if subjective experiences are altered in a more pleasurable way.
In other words, the tennis player who takes something for his nerves will actually play worse than if he had abstained, although the drug may cause him s to think he has played better.
Just as the original Mickey Finn mixture of alcohol and chloral was a veritable bombshell, so alcoholic drinks taken on top of modern sleeping pills, such as the benzodiazepines, can cause a greater degree of incapacity than would be caused just by the sum of their parts. This is one of the major common side effects of sleeping pills.
Irritability and aggression
If you take a drink in the peaceful surroundings of your evening armchair, you may fall asleep. Alcohol consumed in the afternoon by spectators at the sports stadium, for example, does not always lead to sleepiness; it can lead to aggressive behavior and fighting.
Everything depends on the circumstances. And just as people may say foolish and hurtful things, and after into fights after drinking alcohol, so they may after taking the other drugs that promote sleepiness.
The drugs may be sold to soothe the nerves, but-as we have seen-they also blunt your judgment; and on occasions can lead to unpredictable outbursts of temper under provocation.
Careful laboratory tests have shown that when deliberately provoked in conversation, people’s tempers are more easily unleashed when they have taken a pill containing cholordiazepoxide (Librium) than when they have taken an identical-looking pill that is inactive, even though they do not know what the pills contain.
In our own research we conducted a large study with twenty-one volunteers over about nine months, during which they took, for stretches of weeks at a time, one kind a of pill or another.
We coded the pills so that neither we nor the volunteers knew which drug they were taking at the time they were taking it.
During the 450 volunteer-weeks of the study there were seven serious incidents. There was the woman who started weeping and quarrelling with the employer she had worked with quite happily for years.
There was the housewife who became more and more depressed and irritable and filled with impulses to murder a member of her family. Another housewife got into other difficulties by becoming bad tempered at home.
When eventually we broke the code and learned who had been taking which drugs when, we discovered that all the seven incidents had occurred when the volunteers involved had been taking 30 mg flurazepam (Dalmane) at bedtime.
The Dalmane-taking had only occupied 63 out of the 450 weeks. During the other weeks either inactive pills or a more modern sleeping pill-lormetazepam (Noctamid)-had been taken as the alternative.
It could not be explained by chance and we had to conclude that the Dalmane had actually been the cause of the trouble.
The reason why this particular drug is best avoided is because it accumulates in the body’s tissues as the days go by, and so there is bound to be a large quantity active throughout the day, instead of just at night.
Most of you will have heard of the DTs, or delirium tremens. What typically happens is that a heavy drinker of alcohol falls ill and so is prevented from having his usually drinks.
Then a couple of nights later he becomes restless, twitching, unable to sleep, all of a tremble, filled with terror at the sight of horrible visions, all of a tremble, filled with terror at the sight of horrible visions, and possibly even has epileptic seizures.
Just the same can happen when accustomed heavy intake of barbiturates stops, or any other sleeping pill, though the picture is less severe after taking the benzodiazepines.
DTs is the extreme result, but the same troubles arise to a lesser degree whenever any sleeping drug is stopped after being taken regularly in the prescribed dosage.
Why should this happen? It is because the brain is always adapting, changing to meet new circumstances, so that if it finds itself in the presence of a strange chemical never intended by nature to be present in the brain fluids, it adapts itself to counteract the effects of the chemical.
This shows the withdrawal rebound after weeks of taking one of the short acting sleeping drugs. The rebound effects after prolonged intake include difficulty in getting to sleep, fewer hours of sleep and more nightmares.
We all have a certain natural degree of anxiety. We all have an individual natural restlessness part of our constitution.
If a drug that reduces anxiety and restlessness is taken for weeks, then the brain gradually changes its own internal machinery over the same period, as if to try and bring back the natural level of anxiety and restlessness.
That means there is, as it were, new equipment in the brain for making us more anxious, more restless. If the drug is now stopped, we are lumbered with the new equipment, and, without the soothing drug, are now more anxious and more restless than we would have been had we never taken the drug.
The adaptational change that brings about the new equipment in the brain to counteract the effect of the drug, is called ‘tolerance’. Tolerance means that whereas when we first took a sleeping pill, it really knocked us out, by the time we have got used to taking it regularly, it has lost much of its old intensity of effect.
Any sleeping pill to some extent ‘loses its effect’ as a result of tolerance, and so when the drug is no longer taken, the new counteracting equipment in the brain causes a rebound into the opposite of the drug’s effect.
A drug that makes you fall asleep more quickly, and have longer sleep, makes you have less paradoxical sleep and less anxiety, will, when you stop taking it, make you experience prolonged delay in getting to sleep, have shortened hours of sleep, lots of paradoxical sleep, and lots of anxiety, with vivid dreams and nightmares.
These effects will be most severe in the first few nights following the stopping of some drugs, a bit more delayed after others’ but it is certain that they will be unpleasant and will persist in diminishing degree for a couple of months. So, stopping sleeping drugs can be difficult!
Just how sharp and immediate this rebound is varies according to the drug. Stopping flurazepam (Dalmane), for example, does not less lead to such severe rebound effects as stopping many other sleeping drugs, because flurazepam accumulates in the tissues over a period of many days and correspondingly takes a period of many days to leave the tissues, so allowing a gradual let-down.
Alcohol gives a sharp rebound, because it is rapidly destroyed in the body over a period of a few hours. You have probably had the experience of drinking more than usual in the evening and then getting something of a rebound, or withdrawal reaction, causing you wake in the small hours of the morning.
The real alcoholic may wake up not earlier than usual, but positively trembling. You also know that someone who drinks a whole bottle of gin regularly each evening is taking a large doses of a potent drug.
The drug is one that induces sleep and relieves anxiety. If someone does this week after week then, before long, he is t rumbling each morning and dying to have another drink. If somehow he were forced to abstain until at 1st he got his evening drink.
In recent years we have realized the disadvantages of cumulative drugs like flurazepam; and one of the newer drugs, triazolam (Halcion) was introduced partly because, if taken at bedtime to induce sleep, it would virtually be gone from the body by morning.
It is destroyed in the body just about as rapidly as alcohol. In many ways it is a sensible choice, but in our research in Edinburgh we have found that if, for three weeks, volunteers take a large dose of triazolam nightly at bedtime, then the effect on them by day is very similar to the effect of alcohol as far as anxiety is concerned (although triazolam is very much safer for the liver and the body’s tissues).
When people take a large dose of triazolam each evening for three weeks they become more and more anxious by day and this must be attributed to a rebound effect in the daytime as a result of repeated intake of the drug at bedtime.
We must emphasize that we were using a large-than-usual dose of 0.5 mg of triazolam and that if only 0.125 mg were used, we would not expect trouble to arise.
However, our experience with triazolam, as a very short-acting sleeping drug, and our unfortunate experiences with flurazepam as a very long-acting sleeping pill, lead us to favor one of the medium short-acting drugs a probably providign the best compromise for general use.
A drug like lormetazepam (Noctamid), I mg, taken at bedtime is half gone from the body by breakfast time and, at the moment seems to us to be the most sensible available.
This does not mean, though, the after several weeks of regular intake, there will not be the inevitable nights of bad sleep in the first couple of weeks after stopping the drug.
The right sleeping drugs for short-term use
So, to sum up, there is a choice between two different types of sleeping drug.
On the one hand are the older benzodiazepines, such as diazepam (Valium) and flurazepam (Dalmane) and barbiturates, such as phenobarbitone (Luminal) all of which will promote sleep and impair your efficiency round the clock and when stopped, not be followed by a sharp rebound.
While on the other hand are the modern short acting benzodiazepines, such as lormetazepam (Noctamid) that leave you bright and alert by day, but which give you quite a sharp shock as soon as you try to stop taking them after a period of continued use.of the two types we think the latter is preferable.
The fact that prior consumption of sleeping drugs can make sleep even worse than it would have been provides an obvious argument against taking them.
However, as this effect is very dependent on the number of consecutive nights you take the drug, there are time when short term use can be beneficial.
Temporary crises such as the death of a close relative or friend or an operation can deprive you of the comfort of sleep when you need it.
Taking a sleeping pill for a couple of nights may prevent this and enable you to cope with the withdrawal rebound. But remember that the more night you take sleeping pills, the greater the rebound when you stop.
As a general rule, we would advise you to try not to take them for more than two or three night successively.
But whether to take them for a few days until a crisis has passed, or for longer depends on your own special circumstances, and is ultimately a matter for you and your family doctor to decide upon.
If you have been taking sleeping drugs for a week or several weeks, or even longer then you must expect to sleep badly in the weeks after stopping the drug.
Your sleep will eventually return to its natural pattern but it may take six to eight weeks, and they can be difficult weeks.
Being forewarned is being prepared. Tenacity may be required, but a successful return to natural sleep is well worth the effort.
Drugs are not the only substances we consume that affect the way we sleep.
Food and drink also play a part, as does indeed, our weight; exactly how and to what extent.
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