A tranquilizer is a medicine which produces calmness. A sedative causes drowsiness. A hypnotic induces sleep. Sleeping pills are hypnotics. They are viewed with suspicion because some of them are habit-forming.

What are habit-forming medicines?

*These are medicines which cause dependence. Psychological dependence is present when the patient has a craving for the medicine. Physical dependence is present when the patient develops tolerance to the medicine, or experiences withdrawal symptoms when the medicine is stopped.

What is tolerance?

*It is the state wherein the same dose of the medicine produces progressively lesser effects. So, higher doses become necessary for the same action. Thus, a pill which used to induce sleep at a particular dose may no longer induce sleep at that dose; higher doses may be required.

What are withdrawal symptoms?

*These include anxiety, irritability, uneasiness, restlessness, sleeplessness, and other symptoms, some of which can be serious. Some withdrawal symptoms are specific to the category of drug that is withdrawn. Withdrawal symptoms develop when the dose of a habit-forming medicine is reduced, or (more usually) when the medicine is suddenly stopped.

All psychiatric medicines are sleeping pills

*Myth! Psychiatric medicines belong to antidepressant, antipsychotic, anti-anxiety, mood stabilizing, pro-cognitive, and other categories; sleeping pills (hypnotic drugs) are just one category amongst these. Some psychiatric medicines, in fact, may have effects opposite to those of sleeping pills.

All sedating medicines are  sleeping pills

*Psychiatric patients are commonly disturbed and need to be calmed; the medicines used may sedate but may not necessarily induce sleep. Notably, some medicines used to treat epilepsy, migraine, allergies, hypertension, and other conditions may also be sedating; these medicines, of course, are not sleeping pills!

Sleeping medicines cause side effects

*True. People (especially elderly people) who use sleeping pills may be unsteady if they visit the bathroom during the night; they may fall and suffer injury. Sleeping pills may also cause an early morning hangover and daytime drowsiness.

The latter results in decreased alertness and slowed reactions, and hence in risks of impaired job performance, accidents, and other adverse consequences. Most sleeping pills are fairly safe, even in overdose (at the worst, the patient who overdoses will sleep for a long time). These medicines, however, can be more dangerous if mixed with other medicines, or if taken in overdose by people with medical or other disorders.

Sleeping pills are habit-forming

*Partly true; the benzodiazepine drugs are the biggest offenders in this category. But, there are some sleeping pills which are usually not habit-forming even if used for many months.

Which are the safe-to-use sleeping pills?

*Melatonin is an over-the-counter drug. It can help induce natural sleep. However, it does not work for everybody.

And, it does not produce sleep unless the patient actually lies down and tries to sleep! Eszopiclone can be regularly used for many months without resulting in dependence. Other sleeping pills, such as zolpidem and zaleplon, can also be regularly used for a few days to a few weeks without risk of dependence; these drugs can be safely used on an intermittent basis for longer periods, as well.

Which are the habit-forming sleeping pills?

*Any sleeping pill, if used for sufficiently long, might become habit-forming; however, the benzodiazepine drugs are the commonest medicines to which dependence develops. Sadly, such addiction is often unintentionally produced when medical practitioners are careless with their prescriptions. Examples of benzodiazepines are alprazolam, lorazepam, nitrazepam, clonazepam, and diazepam.

Which are the commonest habit- forming pills?

*Formerly, it used to be lorazepam; now, it is alprazolam. A guesstimate is that one in 5-10 medical prescriptions includes alprazolam; yet, alprazolam is seldom really necessary especially as equally good and less addictive alternatives are available for all conditions in which it is indicated.

Depending on the dose and the frequency of administration, alprazolam and lorazepam can be addictive even after as short a period as a few days or weeks of regular use. However, the occasional use of benzodiazepines, or their use for a few days only, is usually safe.

How is addiction treated?

*By a very gradual reduction in dose across weeks to months, sometimes under cover of medicines which temporarily replace the sedative action of the pill which is being withdrawn. Some patients may require professional assistance to break the habit; others may find the habit almost impossible to break, even with psychiatric help.

Prevention is better than cure.

Use sleeping pills only if you must; and, if you do, use them for very brief periods; and, if you need them for longer periods, ensure that what you are using has been approved for long-term use.

When is it justified to use sleeping pills?

*When there is a specific medical need, such as for primary insomnia which does not respond to other treatments. And, in persons who cannot sleep because of pain, jet lag, bus travel, anticipation of surgery, or other intermittent events.

The author is Professor and Head, Department of Psychopharmacology, Nimhans and can be contacted at andradec@gmail.com