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Hypnotic Medications
Hypnotic medications are a class of psychoactives whose primary function is to induce
sleep[1] and to be used in the treatment of insomnia and in surgical anesthesia. These
drugs are called benzodiazepines and are related to Valium, which is the most common
and earliest benzodiazepine. When used in anesthesia to produce and maintain
unconsciousness "sleep" is metaphorical and there are no regular sleep stages or cyclical
natural states; patients rarely recover from anesthesia feeling refreshed and with renewed
energy. Because drugs in this class generally produce dose-dependent effects, ranging
from anxiolysis to production of unconsciousness, they are often referred to collectively
as sedative-hypnotic drugs.[2] Hypnotic drugs are regularly prescribed for insomnia and
other sleep disorders.[3] Many hypnotic drugs are habit-forming and addictive. Due to a
large number of factors known to disturb the human sleep pattern, a physician may
instead recommend alternative sleeping patterns, sleep hygiene, and exercise before
prescribing medication for sleep. Hypnotic medication when prescribed should be used
for the shortest period of time possible.[4] These can be very dangerous medications
when taken with other drugs and alcohol.
The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of
side effects such as daytime fatigue, motor vehicle crashes, cognitive impairments, and
falls and fractures. Elderly people are more sensitive to these side effects and a meta
analysis found that the risks generally outweigh any marginal benefits of hypnotics in the
elderly.[5] A review of the literature regarding benzodiazepine drugs concluded that these
drugs caused an unjustifiable risk to the individual and to public health, and lack
evidence of long-term effectiveness due to tolerance. The risks include dependence,
accidents, and other adverse effects. Gradual discontinuation of hypnotics leads to
improved health without worsening of sleep. Preferably they should be prescribed for
only a few days at the lowest effective dose, and avoided altogether wherever possible in
the elderly.[6]
Benzodiazepines are the most well-known and most frequently-prescribed hypnotic
medications, although their use in recent years is being increasingly replaced by newer
nonbenzodiazepine hypnotic drugs and the hormone melatonin. Benzodiazepines are
effective in the short term but tolerance to their hypnotic effects develops after 1 or 2
weeks, thus making them ineffective for long-term use. They are also a cause of hospital
admissions, especially in the elderly who are more sensitive to their effects[3].
Benzodiazepine withdrawal syndrome can also develop upon their discontinuation. This
is characterized by rebound insomnia, anxiety, confusion, disorientation, insomnia, and
perceptual disturbances. Prescription hypnotics are therefore best limited to short term
use to avoid tolerance, drug dependence, and the adverse effects of long term use.[7]
Benzodiazepines tend to exert their hypnotic effects at high dosage compared to the more
moderate dosage needed for anxiolytic effects to be felt.[8] The downside of the hypnotic
properties of benzodiazepines is that they actually worsen the sleep architecture and thus
the quality of sleep.[9] They are also associated with an increased risk of road traffic
accidents.[10]
Atypical benzodiazepines
Atypical benzodiazepines have demonstrated efficacy in treating some sleep disorders.
Limited, inconclusive evidence suggests that tolerance to atypical benzodiazepines is
slower to develop than with benzodiazepines. Data are also limited with regard to longterm effects of atypical benzodiazepines; further research into the safety and long-term
effectiveness of atypical benzodiazepines has been recommended in a review of the
literature.[11] However, these medications also can pose a great risk to patients using
other drugs and alcohol. These drugs affect memory and patients have reported episodes
of activities that they could not recall. For example, there are reported cases wher patients
cooked all night long without any memory of doing so.
These drugs include:
Barbiturates
Opioids
Examples of Benzodiazepines
Estazolam
Flunitrazepam
Lormetazepam
Midazolam
Nitrazepam
Quazepam
Temazepam
Triazolam
Examples of Atypical benzodiazepines
Zolpidem
Zaleplon
Zopiclone
Eszopiclone
Antihistamines
Diphenhydramine
Doxylamine
Hydroxyzine
Promethazine
Melatonin Agonists
Ramelteon
Melatonin
Tasimelteon
gamma-hydroxybutyric acid (Xyrem)
Methaqualone
Glutethimide
Chloral hydrate
Ethchlorvynol
Levomepromazine
Chlormethiazole
Alcohol is also used as a hypnotic drug, though not medically. Alcohol is a poor hypnotic
because its diuretic action interferes with sleep during the latter part of the night. Alcohol
also disturbs sleep patterns, and so can worsen sleep disorders.
References
1. Dorlands Medical Dictionary:hypnotic".
2. Brunton, Laurence L; Lazo, John S; Lazo Parker, Keith L (2006). Goodman &
Gilman's The Pharmacological Basis of Therapeutics, 11th Edition (11 ed.). The
McGraw-Hill Companies, Inc.. ISBN 0-07-146804-8.
3. National Prescribing Service (2 February 2010). "NPS News 67: Addressing hypnotic
medicines use in primary care". Retrieved 19 March 2010.
4. Mendels J (September 1991). "Criteria for selection of appropriate benzodiazepine
hypnotic therapy". J Clin Psychiatry 52 Suppl: 42–6. PMID 1680126.
5. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE (November 2005). "Sedative
hypnotics in older people with insomnia: meta-analysis of risks and benefits". BMJ 331
(7526): 1169. doi:10.1136/bmj.38623.768588.47. PMID 16284208. PMC 1285093.
6. "What's wrong with prescribing hypnotics?". Drug Ther Bull 42 (12): 89–93.
December 2004. doi:10.1136/dtb.2004.421289. PMID 15587763.
7. Frighetto L, Marra C, Bandali S, Wilbur K, Naumann T, Jewesson P (March 2004).
"An assessment of quality of sleep and the use of drugs with sedating properties in
hospitalized adult patients" (PDF). Health Qual Life Outcomes 2: 17. doi:10.1186/14777525-2-17. PMID 15040803. PMC 521202.
8. Montenegro M, Veiga H, Deslandes A, et al. (June 2005). "[Neuromodulatory effects
of caffeine and bromazepam on visual event-related potential (P300): a comparative
study."]. Arq Neuropsiquiatr 63 (2B): 410–5. doi:/S0004-282X2005000300009. PMID
16059590.
9. Barbera J, Shapiro C (2005). "Benefit-risk assessment of zaleplon in the treatment of
insomnia". Drug Saf 28 (4): 301–18. doi:10.2165/00002018-200528040-00003. PMID
15783240.
10. Gustavsen I, Bramness JG, Skurtveit S, Engeland A, Neutel I, Mørland J (December
2008). "Road traffic accident risk related to prescriptions of the hypnotics zopiclone,
zolpidem, flunitrazepam and nitrazepam". Sleep Med. 9 (8): 818–22.
doi:10.1016/j.sleep.2007.11.011. PMID 18226959.
11. Benca RM (March 2005). "Diagnosis and treatment of chronic insomnia: a review".
Psychiatr Serv 56 (3): 332–43. doi:10.1176/appi.ps.56.3.332. PMID 15746509.
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