Sleep plays an integral role in health. A good night’s sleep empowers the body to recover and lets you wake up refreshed and ready to take on the day. Wouldn’t it be great to wake up every morning more refreshed, clear-minded, energetic, and ready to face the challenges you’ll encounter during your day? Unfortunately, if you as a doctor or any of your patient happens to be among the 33-50 % of Indian adult population, who struggle to get to sleep, or who toss and turn all night, or who suffer from frustrating awakenings, then you know first-hand how a good night’s sleep would be a dream come true!¹ The COVID-19 pandemic has increased the magnitude of insomnia across the world since early 2020. The prevention of insomnia consists of a balance of rest, recreational exercise, stress management and a healthy diet.² In the last three decades, inadequate sleep among adolescents in all countries has almost doubled. As doctors most of us across the world prescribe pharmacologic treatments containing Benzodiazepines, isn’t it, despite low-quality evidence of effectiveness or safety, particularly for longer-term treatment.

Based on various studies and surveys, today’s sleep experts estimate that 10% to 30% of adults live with some form of insomnia.² Benzodiazepine abuse has reached epidemic levels and most commonly occurs in conjunction with other drugs. An overdose occurs when excessive benzodiazepines are taken, intentionally for suicide or accidental. Most overdoses occur when benzodiazepines are combined with other central nervous system depressant drugs, such as alcohol and opioids!³ Insomnia is one of the most common symptoms for which adults seek medical advice in outpatient consultations. The prevalence of chronic insomnia in a family medicine outpatient dept. in Bengaluru was reported to be around 33%, and it was associated with increasing age and diabetes.³ In the elderly, 15% to 45% had initial insomnia, 20% to 65% middle insomnia, 15% to 54% late insomnia, while s 10% had poor sleep quality.⁴

Successful behavioral and pharmacologic approaches to insomnia are to be devised once all contributing factors are recognized and addressed. Positive lifestyle changes, and cognitive behavioral therapy are the first-line treatments. But treating insomnia in practice involves sleep-inducing medication, cognitive behavioral therapy for insomnia (CBT-i), or a combination of both.

In my observation of over 55 years, general practitioners in India prescribe a sedating antidepressant medication like Trazodone, Dioxepine, and Elavil for insomnia.  The modern psychiatrists tend to prescribe benzodiazepines such as diazepam, alprazolam, lorazepam and clonazepam for insomnia, especially in patients with mood or anxiety disorders. The prescribed amount ranges from 0.25 to 0.5 mg daily divided in 2-3 doses, for the shortest period possible, as recommended for 2-4 weeks. Intermittent use may help to avoid addiction.^3,5,6

The risk of overdose and its management

Benzodiazepines are relatively safe medications. Acute overdose is rare but isolated benzodiazepine chronic overdose is not uncommon.

Acute overdose: An acute overdose occurs when excessive amounts of benzodiazepines are taken, either intentionally for suicide or accidental. Signs of an acute benzodiazepine overdose include shallow respiration, clammy skin, dilated pupils, weak and rapid pulse and coma. An overdose of these drugs is usually not fatal, but most benzodiazepine overdose deaths are caused by respiratory depression resulting from mixed overdoses with other drugs that have sedating properties such as alcohol and opioids. Flumazenil, a selective competitive antagonist of the gamma-aminobutyric acid (GABA) receptor, is the only available specific antidote for benzodiazepine toxicity.

Isolated benzodiazepine chronic overdose: A recent cohort study of 23,084 young people initiating benzodiazepine treatment and 66,706 initiating a comparator treatment, suggests that the elevated risk of drug overdose with benzodiazepine treatment compared with alternative pharmacologic treatments for sleep disorders is an important safety consideration when treating young people.³

Young people who take benzodiazepines for an extended period are at risk of developing numerous adverse conditions, including tolerance, dependence and withdrawal upon discontinuation. The classic presentation of an isolated benzodiazepine chronic overdose consists of CNS depression with normal vital signs.

If benzodiazepines are taken for 2 weeks or longer, it is recommended that the user should not abruptly stop taking this drug, but gradually taper over an extended period. If stopped abruptly,   symptoms of benzodiazepine withdrawal can occur, which include headache, sleep disturbances, irritability, agitation, convulsions, tremors, nausea and vomiting and psychosocial episodes like severe panic attacks, psychosis, hallucinations and seizures.

Therefore, latest guidelines suggest

• For chronic users: An initial reduction of 25-30% for high dosage, followed by a 5-10% daily to weekly reduced dose.
• For bedtime users: A 25% weekly reduction is recommended for individuals who normally take therapeutic doses at bedtime.
• For day-time users: An initial dose reduction of 10-25% should be implemented in patients taking therapeutic doses during the daytime followed by further reductions of 10-25% every 1-2 weeks thereafter. A substitution taper, which involves first switching to a more stable, long-acting benzodiazepine before continuing to the tapering phase of treatment is also beneficial.⁷

Legal issues, precautions and safety measures: Ethical issues should be diligently dealt with during face-to-face practice and teleconsultation. Though seeking consultation in person is deemed as consent, explicit consent of the patient is required for recording the video-consultation after explaining the limitations of providing professional advice without physical examination.

References

1. Sleep Statistics, Updated December 15, 2022. Available at: https://www.sleepfoundation.org/.
2. Treatments for Insomnia, Austin Meadows, Sleep Product Tester, Medically Reviewed by Alex Dimitriu, Psychiatrist. Available at: https://www.sleepfoundation.org 6 Jan 2023.
3. Bushnell GA, et al. Association of benzodiazepine treatment for sleep disorders with drug overdose risk among young people. JAMA Netw Open. 2022;5(11):e2243215. doi:10.1001/jamanetworkopen.2022.43215.
4. Chaudhury S, et al. Chronic insomnia: A review. Med J DY Patil Vidyapeeth 2019;12:193-201.
5. de Zambotti M, et al. Insomnia disorder in adolescence: diagnosis, impact, and treatment.  Sleep Med Rev. 2018; 39:12-24, doi:10.1016/ j.smrv. 9/06/2017.
6. Guidelines of the Indian Society for Sleep Research (ISSR) for Practice of Sleep Medicine during COVID-19, Ravi Gupta, et.al, Sleep Vigil. 2020; 4(2): 61–72. Doi: 10.1007/s41782-020-00097-2
7. Michael Kaliszewski. How to taper off benzodiazepines. Available at: https://americanaddictioncenters.org, 19/07/22.